Gestational Diabetes: Planning A Subsequent Pregnancy

by KMom

Copyright 1999-2001 KMom@Vireday.Com. All rights reserved.


DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.

CONTENTS

Introduction

So you've had a gd pregnancy. Perhaps now you are wondering whether to have another child.  Some women with gd have minimal interference from the diagnosis, and a generally good experience with the pregnancy and birth.  These women are generally not hesitant to consider more children, despite their history of gd, but may have some questions about what to expect next time. 

Other women with gd have had terrible experiences with over-interventive care, traumatic births, and difficult emotional aftermaths.  These women tend to be very fearful about the idea of more children, even if they strongly desire more, and may be particularly afraid of what a future pregnancy after gd might hold.  Although both subsets of women will find information here, this FAQ is particularly addressed to the women who have had difficult previous births.

Perhaps you had an arduous labor and delivery and are not sure whether or not you can go through that again. Perhaps you needed insulin and hated all the hassle that involved. Perhaps you are afraid that you will become diabetic before the next pregnancy and are unsure what kind of risk that might entail. Perhaps you are wondering whether having more children will increase your chances of diabetes later on, or whether having had gd means that you should have fewer children. 

Maybe you already are sure you will have another child but have questions about what you can do between pregnancies to improve your blood sugar, or how the course of your treatment in the next pregnancy will differ now that you've had gd already.  Perhaps you are hoping that you can find a way to prevent gd from recurring in your next pregnancy.  Or perhaps you had a cesarean previously and are considering a Vaginal Birth After Cesarean (VBAC).  

This FAQ is to help women who are considering another gd pregnancy understand what the risks of recurrence are, what things they can do to help their chances, what tests they should consider before and during the next pregnancy, and what they might reasonably expect in the course of treatment for the next pregnancy.  Since gd as it is treated in the United States tends to involve quite a bit of intervention (lots of prenatal testing, inductions, c-sections, separation of mother and baby, etc.) and these interventions tend to traumatize some women, this FAQ also contains information about emotional factors in considering a future pregnancy.

As always, none of the material here is intended as medical advice, and it's vitally important that you consult your provider with the details of YOUR specific case.  But here are some facts, figures, and anecdotal stories to consider as well.

 

Factors In Considering Another Pregnancy

Some women plan to have a number of children, only to be thrown the curve called 'gestational diabetes'. In the initial gd pregnancy, the initial focus is often simply on getting control, getting through the pregnancy, and seeing the baby safely into the world. Once the baby is born and things have settled down again, the mother may begin to wonder how her gestational diabetes could affect her plans to have other children.  Or the question may not come up until a few years later when the mother begins to feel ready for more children.

To Have More Children or Not To Have More Children

Moses (1996) found that insulin-dependent women in his study on gd recurrence had a much lower rate of subsequent pregnancies than the diet-controlled group in his study.  In his study, 24% of the diet-controlled women had more children within the 5-year study period, while only 8% of the insulin-dependent women went on to have more kids in that time.  There were no significant differences between the two groups (i.e. age or number of kids) that might explain this difference.  

Although the reason for this is unclear, it may be that these women did not choose to have more children because of the hassles of using insulin, or a fear that their gd might get severe and unmanageable if they had another pregnancy.   Or they might have experienced more difficulty in getting pregnant, since high blood sugars and/or a history of cesareans can impair fertility in some women.  Perhaps they were discouraged by health providers or family members from having more children based on their past history of needing insulin. [Anecdotally, some women with insulin-dependent gd report being strongly discouraged from having more children; whether this is a valid pressure is not clear but in most cases, providers should not be making family planning decisions for their clients.]  Or the influence may be more subtle, causing women to re-evaluate the number of children desired because the need for insulin subtly undermined their sense of trust in their body to have a healthy pregnancy and healthy baby.  

It's important to note that while insulin use in a previous pregnancy usually means that insulin will be needed again or that the gd may develop earlier or more severely, sometimes it also happens that insulin may not be needed in a subsequent pregnancy at all.  In the Moses 1996 study, most of the women who needed insulin in the first pregnancy and did go on to have a subsequent pregnancy did NOT end up needing to use insulin again.  While this sample is small and not representative of most studies in that respect, it does show that a need for insulin can sometimes be avoided in a subsequent pregnancy, especially by being more proactive in health habits. 

One question many gd moms ask is whether having more children will increase their risk for getting diabetes.  The answer to this used to be no, but a 1996 study by Peters et al. found that in a group of Hispanic women with gd, those who went on to have another pregnancy had a 3-fold risk developing type II diabetes compared to those women who did not have another pregnancy.  This is a very scary-sounding result to many gd women, who may feel that they must choose between their strong desire for another baby and their desire to avoid or put off type II diabetes. However, please treat this study's results with caution.   Other studies that have looked at the issue of parity (number of kids) have not found it related to subsequent development of diabetes.   It's possible that perhaps in a small sub-group of women especially prone to insulin resistance that more pregnancies might increase the risk for or speed up the development of diabetes, but at this time no real conclusions are possible.  It would be a shame to change your family size plans only to find out later that this study was an aberration or its results did not apply to you.

It's also important to note that this study was mostly of Hispanics, who have a much higher progression to diabetes than most other ethnic groups, so it's possible that this effect may not be applicable to all ethnic groups (and of course may simply be coincidental in this ethnic group).   However, it's worth noting that in the study, every 10 lbs. gained after pregnancy almost doubled the risk for developing type II diabetes, and that losing weight and keeping it off seemed to lower the risk for diabetes (although sample sizes were small), so it may be that patterns of weight gain may be more important here.  In any event, Kmom would strongly caution any gd mother from taking this study so seriously that she limits her desired family size; much more research needs to be done before this study should be used to influence family-planning decisions for most gd moms.  

In summary, it is clear to Kmom from discussions with other gd mothers that many re-evaluate their family size plans after having had gd.  They may be afraid future children might not be healthy, tired of the hassle of gd pregnancies and dietary restrictions, face disapproval of further pregnancies from family or health providers, are afraid more kids might increase their risk for more severe gd or future diabetes, or don't know if it's worth going through all the hassle again. Some women with gd (especially mild cases) have absolutely no hesitation about having more kids, but in Kmom's experience, many are unsure of whether or not to have more.  Some go ahead despite fears and reservations, but some are caught up in a no-man's land of indecision about it, especially if their gd pregnancy or birth was particularly hard or filled with intervention.

Choosing Another Child After a Difficult Birth

Some women, after going through the often arduous process of labor induction and/or c-section, simply cannot bear facing that process again and elect not to have more children, even though they might originally have been considering more. This is a sad consequence of the overtreatment of many women with gd; many of these women may not needed to have had such a difficult birth process, and there were probably things that could have eased the process for at least some of them, even if some intervention was necessary. Far too many births these days are resulting in unnecessary c-sections and difficult births, and this is especially true of many gd cases.

Kmom would urge these moms not to truncate their plans for further children based simply on the way their first gd birth went. GD does not always recur (about 1/3 of cases do not recur), and it's possible the question of all these interventions might even be moot. If you are part of the majority (about 2/3) whose gd does recur, you do not have to automatically face the same management and interventions you did last time. Providers vary TREMENDOUSLY in their approach to gd; some are extremely interventive while others are watchful but not nearly as interventive for the same conditions. If you find a different provider, you might be able to find one who will be less interventive.

And even if you need some interventions, there are some providers that handle even these cases with a lot more flexibility than others. For example, Kmom has interviewed providers that are fine with not inducing for gd, 'let' a gd mom go to 41 weeks even with a VBAC, and don't freak out over a baby predicted to be moderately large.  "Dee", a mom with severe insulin-dependent recurrent gd who had had a very difficult labor and c-section with her first child, found a wonderful high-risk OB who managed her subsequent labor very flexibly. Although they did choose to induce her labor early, the OB strongly encouraged her VBAC (Vaginal Birth After Cesarean) efforts, let her be mobile, use the tub, rock, walk, and use various positions for laboring and pushing, instead of having to be tied down to the bed on her back for the whole induction. Because of this, despite the past history of a difficult labor and c-section plus a number of concurrent complications, "Dee" was able to have a beautiful VBAC with a gorgeous son. What a shame it would have been to have chosen not to have another child based on the way her first birth went!

The point is that your next birth does not HAVE to be like the first gd one went, if it was difficult. The secret for "Dee" was to have excellent blood sugar control and to switch to a new OB who was more supportive of as much  natural laboring as was possible under her circumstances. Studies have found that midwives and family doctors have half the rate of c-sections that most OBs do, and usually have more flexibility regarding inductions and laboring protocols. This doesn't mean that a midwife or family doc is automatically a better choice---there are plenty of them who employ too many unnecessary interventions too!---but that they are less interventive as a group. Conversely, as the case of "Dee" shows, there are great OBs who are very supportive of a more natural approach even in the face of needed intervention. 

It is YOUR job to check out each provider and discover their philosophy of handling gd, but it's important to remember that THERE ARE VAST DIFFERENCES IN HOW PROVIDERS HANDLE GD. Just because your labor was handled one way in the past doesn't mean it has to handled that way in the future.  Don't choose not to have more kids simply because your last birth was difficult. Find a new provider and be as proactive as possible in preventing those same circumstances from recurring; CREATE A NEW BIRTHING SCENARIO FOR YOURSELF.

Emotional Recovery After a Difficult Birth

However, just choosing a different provider with less interventive protocols after a difficult birth may not be enough to make your next birth different. Many women have a great deal of emotional baggage left over from their previous births. It's very important to address these issues as much as possible in order to confront and free yourself from your fears for the next pregnancy and birth. You may not be ready to deal with this right away after the first gd birth; sometimes it takes a couple of years before women are really ready to deal with all the things that happen in birth. Sometimes women think they are 'fine' with everything, only to find later that they actually do have emotional baggage to deal with. Some women do recover just fine without any long-term problems, of course, but don't feel bad if you have issues still to deal with afterwards. This is very common, and particularly so after a difficult or traumatic pregnancy or birth.

There is much more information on this subject in the websection on GD: Postpartum Care; be sure to read that section for further discussion of emotional recovery. Several other excellent resources include the books, Rebounding from Childbirth: Towards Emotional Recovery by Lynn Madsen, and Transformation Through Childbirth, by Claudia Panuthos. These books are absolutely outstanding resources for helping women understand and process the life-changing experiences of pregnancy, childbirth, and motherhood. Resources for finding these books can be found in the reference section.

You may find that you do some healing in the beginning and then move on to other tasks thinking you are done, but then something triggers your need to deal with the birth again, and you re-encounter the healing process again. The healing process often proceeds in a 'spiral' pattern like this. Don't wallow in self-pity or allow yourself to hold on to your grief forever, but don't be surprised if healing takes a while and occurs in stops and starts. Emotions are very tricky things; they do not heal as cleanly and straight-forwardly as nerves and tissue and muscle.  And remember, the spiral of recovery always moves UP and into the light.

Emotional healing is often a long-term project. Personal issues of long standing are often intertwined with birthing issues, thorny issues that defy easy solutions or quick platitudes. Sexual abuse, violence, control issues, even dieting and body issues can become intertwined with your healing process. Don't expect quick, easy answers; healing usually occurs on a number of different levels, and over a longer time period than you might expect. Often, considering a new pregnancy (and going through it!) is a trigger for a great deal of renewed fear and anxiety, but this is actually an opportunity for healing and resolving issues, not a negative thing. Pam England in the book, Birthing From Within (another excellent resource), states that "Worry is the work of pregnancy" and that this can be a positive force if used for healing.

So take your worry and USE it. Explore your own issues and how they may have impacted your birthing process in the past. Explore your feelings about your medical care in the past pregnancy, and what you want for future pregnancies. Define your fears for future pregnancies and figure out ways to help resolve or deal with those fears. Take your concerns and your grief and your joys and CHANNEL them into positive energy for the next pregnancy and birth. Use journaling, artwork, support groups, or therapy with a counselor who specializes in birth issues.  Empower yourself!

 

Health Habits Between Pregnancies

It is important to try to have the best possible health habits between pregnancies so as to try to prevent gd from recurring, prevent it from becoming worse, or prevent it from progressing to full-blown diabetes between pregnancies. If you can avoid deteriorating blood sugar control, your chances for a good outcome in the next pregnancy improve significantly, and you might be able to avoid a gd diagnosis altogether. So which habits are the most important to emphasize?

Sensible Nutrition

Of course, it is very important to practice sensible nutrition between pregnancies.  Continuing the basic tenets of your gd food plan is probably a good idea, as long as that plan allowed for sufficient calories for the breastfeeding period (a minimum of 1800-2000 calories, preferably more at first).  Moms with a history of gd should probably:

Excellent nutrition while breastfeeding is very important.  Although nursing moms can get by on less-than-stellar nutrition, over the long-term this can take a toll on their bodies.  Be sure to continue a prenatal vitamin, and if nursing long-term, you might want to consider supplementing with extra folate or other B vitamins, Omega 3 fatty acids (fish oil or flax seed oil capsules), vitamin C, or vitamin E.  

Of course, no supplements can replace regular consumption of plenty of leafy green veggies, lots of dark orange fruits and veggies, and enough vitamin C fruits and veggies.  Eating whole foods (as close to their natural state as possible) increases fiber intake (which improves blood sugar levels) and greatly improves the amount of nutrients that are bio-available to you.  And of course, plenty of fluids in the diet is VERY important for all people, but especially so for nursing moms.  

Continuing a gd food plan between pregnancies doesn't mean that you can't have a treat now and then, just that MOST of your regular food consumption should follow the above guidelines.  Excessive carb intake at any one time is particularly to be avoided.  Whether or not you decide to try and lose weight between pregnancies, women who have had gd should try and maintain most or all of the habits promoted by gd food plans, as these are just generally healthy guidelines for anybody.  If maintaining all of them at once seems too overwhelming at first, target a few that seems more attainable, like strongly reducing or cutting out all pop and juice, eating smaller but more frequent meals, getting more complex carbs instead of refined carbs, etc.  

Although once you are past pregnancy and have tested normoglycemic again, you certainly 'can' revert to old eating habits that were perhaps not the most optimal, but you probably increase your risk for gd in future pregnancies as well as type II diabetes eventually.  Keeping the dietary changes of a gd food plan does not guarantee that you won't get gd again or type II diabetes eventually, but it does probably lower the risk for it.  And it generally just healthy eating anyhow.  

Weight Loss

Women who are larger and who have had gd in the past are almost always told to go lose weight after their pregnancies.  [<Insert sugary-sweet, ultra-condescending tone>  "We'll deliver the baby, and then we'll get some of that weight off of you," is the way one nurse put it to Kmom, like she was talking to a kindergartener who was too stupid to have ever considered weight loss before.]  However, weight loss may or may not be a good idea for all women.  Each person's unique history and circumstances must be taken into account.   

Doctors promote weight loss as a treatment for blood sugar concerns because weight gain does tend to worsen insulin resistance.  Thus it seems logical that losing weight might help improve insulin resistance.  And for a percentage of type II diabetics, weight loss--even a small amount---does often improve blood sugar levels and related readings.  However, it should be noted that NOT ALL diabetics are helped by weight loss.  

There seems to be a distinct group that is strongly sensitive to even small weight changes and is greatly aided by weight loss ("responders"), and other diabetics who do not seem to respond well to weight loss ("non-responders").  Watts (1990) found that about 40% of obese diabetics studied were "responders" and had their blood sugar levels significantly improved by modest weight loss (about 20 lbs.), while the other 60% were "non-responders" and did not show any real improvement in blood sugar levels with a similar weight loss.    Other research seems to show that at most, up to 50-60% may respond to weight loss, while the rest do not.  And study after study shows that weight loss, especially for diabetics, is particularly difficult and rarely permanent.

Furthermore, dieting (even when done sensibly) tends to deplete the body of vital nutrients, most notably B vitamins like folic acid (important for preventing birth defects).  Beginning a pregnancy at less-than-optimal nutritional condition is not a good idea for either the mother or the baby.  And crash dieting (or sudden strong weight loss) can impede breastmilk supply and release stored toxins, which is not good for the nursing child.  Therefore, dieting after a gd pregnancy presents some possible concerns. 

[Lest mothers be tempted to not breastfeed or to wean early in order to diet more strenuously, please note that mothers generally lose weight more efficiently when breastfeeding because of the energy demands on the body.  In addition, gd mothers who breastfeed have been found to have better blood sugar levels and 'good' (HDL) cholesterol levels, and one preliminary study shows that breastfed babies got diabetes as adults at lower rates than those who were formula-fed.  Dieting should NOT be chosen over breastfeeding, and especially not in women who have had gd. It doesn't have to be an either/or choice. See GD and Breastfeeding References.]

Weight loss may be also may be harmful in women who have tended towards yo-yo dieting in the past.  In some women, it can increase the amount of weight gained in the next pregnancy as the body strives to re-establish its setpoint. Anecdotally, Kmom has received reports of women losing 80 lbs. before pregnancy, only to gain 100 lbs. during the pregnancy, despite trying not to!  Excessive pregnancy weight gain can increase macrosomia in the baby, and might even increase the chances of gd.   

And if weight loss leads to yo-yoing, it might increase insulin resistance compared with simply maintaining a stable (but higher) weight.  French (1996) found that adults who gained a lot or had significant weight fluctuations had a significantly increased risk for developing diabetes; those who lost weight and maintained the loss permanently strongly decreased their risk for diabetes.  

Thus the weight loss picture is cloudy and unclear.  For some women with a history of gd, weight loss MAY help decrease their chances for gd in subsequent pregnancies (although data is quite limited on that), and if maintained very long-term, probably decreases their chances for type II diabetes.  However, the vast majority of weight loss is not maintained, often leads to chronic yo-yo dieting, and this may have a very serious effect on health.  Some studies suggest that yo-yo dieting increases diabetes, hypertension, and/or mortality; some do not.  But since very few people maintain weight loss for even the 4-5 years required to call the loss 'long-term', the wisdom of strenuous dieting to achieve temporary weight loss is questionable.  

However, if weight loss is to be considered between pregnancies, it should be done SENSIBLY and with time to stabilize the weight to assure optimal nutritional stores before the next pregnancy begins.  Although authorities used to insist on massive weight loss for all in order to reach 'normal' weight guidelines, most now suggest concentrating on modest weight losses of around 5-10% of body weight.   This should also decrease the chances of malnutrition from extensive dieting.  It may also be a more achievable and sustainable goal (although it should be noted that even small weight decreases can set off wild yo-yoing in some women).   If you are considering weight loss, aim primarily for improving diet and exercise habits, and secondarily for a small, slow weight loss that is sustainable.

However, weight loss attempts should NOT begin immediately after the first gd pregnancy ends, but should wait until at least 8 weeks postpartum so that that breastmilk supply is well-established and will not be threatened.  Then it should be done mostly by increasing exercise and eating healthily, not by significant caloric reduction until much later.  La Leche League states in The Breastfeeding Answer Book that nursing moms generally should not fall below 1800 calories per day for the first months of nursing, a figure agreed with by Eileen Behan, the registered dietitian who wrote Eat Well, Lose Weight While Breastfeeding.  Even at that level, she cautions that mothers will need to pay "very close attention to getting adequate supplies of calcium, zinc, magnesium, vitamin B6, and folic acid.  It is important to realize that when calories are restricted, food is restricted and nutrients may be harder to get."  

Whether weight loss between pregnancies is a sensible choice for YOU or not is an individual decision.  For women who were thin in childhood and gained a lot of weight as an adult, weight loss may be more feasible and may result in the greatest health improvements.  For women with infertility issues such as PolyCystic Ovarian Syndrome (PCOS), weight loss is especially difficult but may be worth considering because it may lessen the risk of miscarriage in subsequent pregnancy.  For women who have been heavy life-long and who have only increased their fatness through yo-yo dieting, keeping a stable weight (and preventing additional increase) may be more sensible than another trip on the diet merry-go-round. Each woman must decide for herself what is the most sensible course.   

However, ALL groups can benefit from increased exercise, and barring medical impediments, exercise should be the main cornerstone of any health improvement campaigns between pregnancies.

Exercise

Probably the most important habit to emphasize between pregnancies is exercise. Exercise has been shown to help prevent or delay type II diabetes in a number of populations, even when weight loss is not part of the prescribed program. Some books estimate that you can lower your risk of type II diabetes by 40% if you exercise regularly. Dye (1997) found that obese women were able to cut their rates of gd in HALF by exercising regularly. Regular exercise helps increase glucose uptake and lessens insulin resistance, helping you use your insulin better and making it so that you need less. It also increases your metabolism so that you use your energy more efficiently and burn more calories even after the exercise has ceased. 

However, it must be done at least every other day or the cumulative benefits of the metabolism increase are lost. To be most effective, you should probably plan to do some exercise of some sort nearly every day of the week. You can take a day or two off a week, but preferably not in a row in order to maintain the metabolic benefit. The exercise need not be elaborate or expensive; a simple daily walk or swim works beautifully.  Even moderate exercise has been shown to help blood sugar levels, and some research even shows that exercise can be broken into small 10-minute blocks throughout the day and still be helpful.  

Exercise is one of the most powerful tools around for addressing blood sugar concerns proactively.  Many women have avoided gd recurrence or needing insulin simply by increasing their exercise levels.  Just about EVERY mom with a history of gd should strongly consider increasing their exercise routine.  

 

Once You are Pregnant: Nutrition

If you are already pregnant, it is important to focus on extremely healthy habits as soon as possible. Although it's best to do this from the very beginning (or before), it's never too late to start.

Remember, a gd food plan is really not that different from most pregnancy nutrition guides in terms of amounts; it's more the TIMING and PATTERN and FOOD COMBINATIONS that are different. The focus in a gd food plan is on breaking up the food intake into smaller portions and spreading them out throughout the day, and in taking in protein with your carbs. The advantage of this is that it minimizes the demands on your system for dealing with the blood sugars (bG), does not overtax your insulin response, and provides a more consistent amount of energy so you do not have strong swings of bG, high and low.

Some typical suggestions for nutrition include:

  1. Eat smaller meals and snacks, but eat more frequently ('grazing')
  2. Make your eating patterns even and consistent; never skip meals or go for a long time without eating
  3. Always eat protein with your carbs (VERY important!)
  4. Eliminate ALL or virtually all sugar and refined carbs from your diet during pregnancy
  5. Eat when you are nauseous, even if you don't feel like it (protein every 3 hours)
  6. Emphasize nutrient-dense foods and quality over quantity
  7. Cut back or be very cautious with highly refined or simple carbs; increase fiber intake
  8. Limit carb intake at any one time; know the carb loads of typical foods
  9. Have a good bedtime snack (with protein) to help stabilize night-time blood sugar
  10. Make your breakfasts very small and conservative, and be sure to have protein

 

1. Eat smaller meals and snacks, but eat more frequently ('grazing')

This is extremely important to do. You will need to eat lightly about every 3 hours. Your total intake over the day may be the same as other pregnancy food plans, but it will be spread instead over 5-6 meals/snacks, instead of concentrated in 2-3 larger carb-heavy meals. This allows for more efficient response by your system, avoids an overload of too many carbs at once, and avoids large swings in blood sugar from high to low and back again. Some feel that it is this SWING from highs to lows and back again that may predispose susceptible people to gd later in the pregnancy. It is your goal during pregnancy to keep your blood sugar as even as possible throughout the day and night (euglycemia).

2. Make your eating patterns even and consistent; never skip meals or go for a long time without eating.

In order to help keep your blood sugar as even as possible, keep your eating patterns very even and consistent.  It's especially important not to skip meals or to go for a long time without eating.  Many women make the mistake of skipping a meal, then eating a larger meal later on.  This makes the blood sugar swing from too low to too high.  Eating a small snack every few hours helps prevent this, but it's important to keep the intake and schedule pretty consistent from day to day.

It's also important not to fast too long overnight; between 8-10 hours is about right.  If you go longer than that, the body's blood sugar levels dip too low and the body must access the sugar stored in the liver (glycogen) or burn fat stores for energy (producing ketones which are not good for the baby).  Eat a good snack shortly before bedtime (see below) and then fast for no more than about 10 hours.   Some women do better with 8 or 9 hours, so experiment a little bit and do what seems to work best for your body.

3. Always eat protein with your carbs

Protein slows down the absorption of carbs, and makes the energy available more evenly and for a longer period of time. It is extremely important to have protein whenever you have more than one carb. Protein is particularly important with the morning meal and with the bedtime snack. You don't need huge amounts of protein, just frequent small servings with your carbs. Over the day, this will total up enough to help baby grow optimally and to possibly help avoid the risk of Pregnancy-Induced Hypertension (PIH, a.k.a. pre-eclampsia). 

One of the harder things, though, is finding convenient, varied forms of protein in small amounts. String cheeses are convenient, portable, and low-fat; hard-boiled eggs are a good portable choice too (you don't need to worry about cholesterol intake during pregnancy unless you have previous high blood lipids). Other options include turkey ham (cubed ahead of time), slices of meats (but be careful of those that add sugar or nitrites), slices of cheeses, servings of cottage cheese, peanut butter, and eggs in other forms. Lentils and beans are a great source of protein, too, but count as a starch AND a protein in one. However, they make your blood sugar rise the least of all carbs and have many important nutrients, so they can be an excellent food for gd.

4.  Eliminate ALL or virtually all sugar and refined carbs from your diet during pregnancy

Although it may not be easy, you would be wise to cut ALL sugar consumption or  allow only an extremely occasional treat.  Sugar is a simple carbohydrate that is processed extremely fast, creating a strong challenge for your system. When a sugar reaction is combined with the insulin resistance that happens naturally from placental hormones, it can overwhelm and fatigue your system. It also makes your blood sugar spike high and fast, then causes it to crash later, and then precipitate an intense craving for more sugar (a vicious circle). It is not only the high blood sugar that is the problem, it is the swing from highs to lows that cause a problem. Although many women find it hard to do, it IS best to eliminate or nearly eliminate sugar from your diet in pregnancy.  Also remember that many refined carbs like breakfast cereal or white bread can cause an even stronger bG reaction than sugar. Many midwives report that simply eliminating sugar and refined carbs (and eating more frequent protein) is enough to prevent most cases of gd in their practice.  

5. Eat when you are nauseous, even though you don't feel like it

Most doctors will tell you that it doesn't matter in the early days if you eat or not when you are nauseous and that baby will be fine regardless. However, it is quite possible that this advice can lead some people into a chronic pattern of low blood sugar for long periods (which makes the nausea worse), then strong swings upwards when you do eat and your body suddenly has to process all that energy. Again, it may be the swings of blood sugars that precipitate the gd problem, along with insulin resistance. {Nausea and uneven bG was a definite factor for Kmom, first-time around!} Some midwives feel that many cases of borderline gd are really cases of hypoglycemia that get out of control.  Therefore, it is important to keep an even intake, even when you feel too sick or wrung out to eat.

Hint: It is very difficult to eat when nauseous, but many women find that forcing themselves to eat a small amount of protein every 3 hours or so actually helps ease the worst of the nausea, once they get past the difficulty of eating. If you are feeling nauseous, it is usually your body's signal to eat, as contradictory and difficult as that may seem. You don't have to eat great amounts, but take a small amount of protein and if possible, a small amount of carb (crackers and cheese, bread and peanut butter, etc., or simply a piece of string cheese). So although eating every 2-4 hours does not prevent all morning sickness, it may help keep yours from getting out of control, and keep it shorter and more manageable. If you have trigger foods, substitute others that can give you the necessary vitamins and minerals. {Kmom couldn't look at vitamin A veggies without retching; cantaloupe was a good substitute.} You may not be able to eat completely normally, but do try very hard to eat every 2-4 hours in small amounts. Be sure to have a good bedtime snack, complete with protein (see below), and review the ideas for dealing with nausea listed in the websection on Dealing With Nausea.

Anecdotally, Kmom has found that many women with gd experienced major bouts of long-lasting or severe nausea, and that often this improves once on a gd eating plan. This seems to support the idea that low blood sugar and wild swings of bG tend to be associated with development of gd. Force yourself to have at least some intake, and make it as healthy as you can. 

6.  Emphasize nutrient-dense foods and quality over quantity.  

Dr. Sears, author of The Birth Book, feels that you don't really have to eat much more in pregnancy, but you do need to eat better, meaning more high-quality and wholesome foods. When you examine the lists of foods that are highest in the various nutrients needed in pregnancy, you will find several foods that are common to many lists.  Emphasize these foods in your diet.  

Every day, have a salad or suitable substitute.  Emphasize nuts and seeds, fresh fruits and vegetables, and whole grains like brown rice and wheat bread.  Increase the number of times a week you eat legumes like lentils and dried beans.  Focus on the fruits and veggies that are the MOST nutritious, such as spinach, broccoli, sweet potato/yam, carrots, potatoes (with skin), asparagus, kiwifruit, oranges, cantaloupe, papayas, mangoes, and strawberries.  Also try to eat them as fresh as possible. The closer to nature they are, the more nutrients they contain for the baby.

7. Cut back or be very cautious with highly refined or simple carbs; increase fiber intake.  

Remember, it's not just about reducing the amount of carbohydrate you eat, but also about improving the TYPE of carbs that you eat.  Eliminate junk-food and refined foods such as white breads, highly processed baked goods, pop, french fries, etc., and minimize foods such as cold cereals, hamburgers, and fast foods.  The most carb-intense foods out there include pies (especially fruit pies), syrup, muffins, sodas, bagels, pasta, and cereals (especially with fruit).  

Studies show that higher-fiber foods tend to produce less of a blood sugar response than refined foods, so when you choose foods like rice or bread, be sure to have brown rice or whole-wheat bread.  It's not that you can't ever let an 'impure' food cross your lips in pregnancy, but you REALLY need to cut back junk foods and highly refined products as much as possible.  Although some pregnant women can tolerate these foods, women who have already had gd should be extremely careful about these!  Some midwives report being able to help women prevent a recurrence of gd simply by cutting the "white" foods out of their diet---white rice, white bread, highly refined foods with lots of white flour, sometimes potatoes, etc.

Be aware of simple carbs vs. complex carbs in your diet, and be very cautious about consumption of the simple carbs like fruit juices.  Sweetened and unsweetened juices should be avoided as much as possible since they stress the system just as strongly as regular pop does. Many women (including Kmom in her first pregnancy) increase their consumption of fruit juice during pregnancy thinking that they are being healthy, only to find out later that they created intense blood sugar spikes and insulin response by drinking lots of fruit juice. Drinking even moderate amounts can cause very strong spikes of bG, and the nutrition benefit is not that significant. It is better to eat the fruit itself, which has fiber to help slow down the bG spike, and more nutrients to boot. Although you can probably have occasional small amounts of fruit juice, you should most often choose water instead.  (Try drinking it ice-cold---it tastes best that way!)

Be cautious as well about the amount and timing of milk consumption, since it also acts as a simple carb. Milk can be an appropriate part of a pregnancy diet if you desire it, BUT it can also cause strong bG spikes in women that are especially prone to insulin resistance. Because it has fat and protein to help slow down the process it is better than juice, but it does produce a significant response. For example, when insulin-dependent diabetics have an episode of very low blood-sugar (and are in danger of passing out, etc.), the experts often recommend either juice or milk as the treatment of choice.  This shows that women who may be prone to blood sugar problems in pregnancy should be very cautious in their use of fruit juices and milk.  

Some women whose bG is very sensitive find that it's best to avoid milk in the morning when bG tends to spike highest. Other women can handle it fine then, as long as protein is eaten too and the rest of breakfast is not very carb-heavy. If you strongly desire some milk, it's most optimal to have it later in the day (i.e. before bed is good) and be cautious about combining it with other carb-intensive foods. Generally speaking, you should be cautious about adding the carbohydrates in milk to the carbohydrates in a meal as it can create a carbohydrate overload at one time. And in general, avoid mixing fruits and milks together, since they both tend to raise bG quickly and strongly.  Finally, if you have a history of large babies (9 lbs. or more) in your family or your partner's family, you might want to be particularly cautious in the amount of milk you consume.  Although not all agree, many midwives feel that drinking a lot of milk tends to exacerbate a tendency towards larger babies among women prone to that.  Foods like cheese, yogurt, almonds, calcium-fortified O.J., and green leafy veggies can give you the extra calcium you need, but be very cautious about too much milk.  However, if you cut milk out of your diet, do be sure you are still getting enough protein from other sources. 

8.  Limit carb intake at any one time; know the carb loads of typical foods.  

One serving of carbohydrate, for example, equals 15 grams, which is about what you find in one piece of bread.  Most meals should be limited to about 45-60g of carbs, or 3-4 servings.  That means ALL your carbs----fruits, milk, starches, starchy veggies, sweets, juice, etc.!  So it's very easy to overload on carbs at any one meal.  Become adept at counting carbs so that you can roughly estimate the amount being consumed at any one time, and be sure that you always have some protein as well if you take in anything more than 1 carb (15 grams).  Some women might want to be even more cautious and limit intake to 30-45 g of carbs at any one time (2-3 servings), and be especially cautious of 'danger' foods.  

For example, if you had a small potato, a roll, a glass of milk, an orange, and some corn or peas with your steak dinner, you would have already exceeded the carb allowance.  Put all together these add up to 5-6 carbs (a roll often has 2 carbs, or 30g).  You want to keep your intake to 45 g or so on average, or about 3 carbs most of the time.  So instead, you might want to have the potato, the orange, some broccoli, and some peas with your steak.  That way you get the benefit of all the vitamin C in the orange, potato, and broccoli (which tends to increase the absorption of the iron in the steak), 4 nutrient-rich veggies and fruits to add to your daily total, and no milk calcium to interfere with the iron in the steak.  (You can have the milk instead later that night at bedtime, along with some protein, if you really crave milk.)

You should be very cautious with 'danger foods', foods that are very carb-intensive and can cause large swings in bG. Foods such as fruit yogurts, muffins, croissants, bagels, bean burritos, cold cereals, etc. tend to contain high amounts of carbs and raise blood sugar strongly.  It's not that you can't EVER have these foods, but you should be extremely cautious in their use, and be sure to read labels so you can accurately estimate the amount of carbs you are having.

For example, most fruit yogurts contain about 45g of carbs, or the equivalent of 3 carb servings in one small container. Muffins often contain a huge 45-60g, since they usually have flour, fruit, and sugar, all carbohydrate ingredients. Bagels usually contain about 45 g too, and if you have one with fruit in it, the totals can go even higher.  Cold cereals tend to be extremely carb-intensive, and many people eat larger servings than what is given on the label.  Then combine the cereal with the carb in milk and you have an extremely carb-intensive meal.  If you want to have cereal, try to choose the least carb-intensive ones (read the labels!), avoid the ones with fruit or that have sugar near the top of the ingredient list, and only have a small bowl. Also consider having it later in the day instead of in the morning when blood sugar tends to be highest. 

Also remember that all carbs are not created equal.  Some types of carb tend to cause a much stronger blood sugar response than others.  For example, corn flakes or white rice create one of the strongest responses in most people, often greater than that of sugar!  White bread also creates a strong response, as does pasta.  So if you want a starchy food at your meal, most people generally do better with a potato (in the skin) than with a roll, or by having brown rice instead of white rice. However, some people can't tolerate potatoes or rice in any form at all.  Sweet potatoes sound like they would create a problem, but most non-diabetics can handle them just fine (if they are eaten without the brown sugar and marshmallows!), and they are one of the most nutritious vegetables around.  Beans, lentils and other legumes DO have to be counted as carbs, but they are so high-fiber that they tend not to create a very high blood sugar response compared to breads, etc, plus they are high in protein and many other valuable nutrients such as folic acid. 

Also be aware of hidden carbs; some foods that don't seem like carbohydrates actually are. Many canned spaghetti sauces contain carbs.  Lentils and beans are an excellent food but they count as both a protein and a starch, due to their carb content. Peas, corn, yams and potatoes offer plenty of nutritional value, but must be counted as a starch as well as a vegetable. Many diet foods, like sugar-free pudding, also count as a carb serving; read the label to know for sure. You don't have to avoid corn or beans, just be sure to count them as carbs too.

In general, it's best just to avoid or strictly limit junk foods, simple carbs, and the most carb-intensive foods completely in pregnancy.  Substitute more complex carbs instead of highly refined ones; even if both contain 30g of carb, you are more likely to have a strong response to the refined carb.  Finally, read labels carefully for the serving size and carb content of each food; you'd be surprised at how helpful this can be!  Remember, one serving carb equals 15 grams, and you generally want about 45g per meal.

9. Have a good bedtime snack (with protein) to help stabilize night-time blood sugar.  

Many women suffer unnecessarily with very strong pregnancy nausea, and this is often caused (or made worse) by a dip in blood sugar overnight.  It has been Kmom's observation that many women prone to insulin-resistance or high blood sugars tend to be especially prone to problems with nausea, creating a vicious circle that only gets worse.  Although it's not usually possible to eliminate all pregnancy nausea, it is usually possible to moderate it and keep it from spiraling out of control. One of the ways you can do this is to eat some protein every 3 hours or so (as noted above), and also to have a good bedtime snack that also contains protein.  

In pregnancy, the body tends to intensify its blood sugar reaction to eating to get more energy for the growing baby and to use up MORE blood sugar overnight for a steady energy supply, resulting in a lower blood sugar in the a.m.  This means you have to watch your intake during the day to be sure you don't overload your system with too much carb at once, and to eat a bit more at night to be sure that your blood sugar doesn't drop too low overnight.   

So it's important to have a good snack before bedtime, and it's vitally important that this snack contain protein to help the blood sugar remain more steady throughout the night.  Otherwise, you tend to get a high spike from the carbs you consume, and then a blood sugar crash in the middle of the night as the energy runs out.  Your blood sugar then either gets too low (causing a lot of morning nausea) OR your body compensates by accessing other energy sources such as body fat, the by-products of which are ketones, which in large consistent amounts can be harmful to the baby.   So it's a very important preventative step to have a good bedtime snack with protein.  

This snack is not a meal and doesn't have to be large; 1-2 servings of protein, and 1-2 servings of carbs is enough for most women.  If you want to, you can have your milk at bedtime as one of your carbs.  You don't want to eat just before bedtime, but neither do you want it to be hours beforehand, either.  Time it so that your morning meal occurs about 8-10 hours after your bedtime snack.  So if your bedtime is about 10:30 p.m.,  eat your snack around 10 p.m., and then your morning breakfast at about 7:30 or 8:00 a.m.  Or if you are a night-owl like Kmom, move those times back.  This is not rocket science; timings don't have to be exact, but it is generally a good idea not to fast for anything less than 8 hours or anything more than 10-11 hours. 

10. Make your breakfasts very small and conservative, and be sure to have protein.  

There is an early morning rush of hormones that make most pregnant women more insulin-resistant in the morning.  In addition, the typical American breakfast is extremely carb-intensive and often does not have much protein in it.  Given the tendency for blood sugar to be react the strongest in the morning, this is a disaster waiting to happen for women with a past history of gd.  

Keep your breakfasts small, omit milk and fruits as much as possible, and be sure to eat protein with it. It may seem strange to have such a small breakfast, but if you get hungry, you can eat a snack 2-3 hours later to help give you enough energy until lunch. Your breakfast should have a starch serving, a fat serving, and most importantly, 1-2 PROTEIN servings, which will serve to slow down the carb surge from the other foods. Try to avoid fruit or milk at breakfast, since these foods tend to cause quick, strong blood sugar reactions and you are least able to tolerate this in the morning.  You can have these foods later in the day.  Some women can tolerate a bit more than this at breakfast; if you have a home monitor you can check and see what works for you.  However, generally it's a good idea to err on the side of a smaller breakfast rather than a larger one for most.

Some women may be tempted to skip breakfast entirely.  This is also a disaster waiting to happen, and you should NEVER skip breakfast, especially in pregnancy.  Your body must provide energy for a growing baby 24 hours a day, and reserves tend to drop overnight.  If you do not eat breakfast, your body is subjected to a too-long fast, which is bad for both you and the baby.  This will also tend to increase the occurrence, length, and severity of pregnancy nausea.  Basically, the rule of thumb in pregnancy is to NEVER skip meals, no matter what.  You don't have to eat a lot, but you do need to eat regularly (see above). 

These are some specifics on basic ideas that may help avoid or minimize gd recurrence.  If you want even more specific nutrition ideas, read the FAQs on GD Nutrition or GD Prevention.  

 

Probability of GD Recurrence

Just how likely is it that your gd will return in a subsequent pregnancy? The most-often quoted statistic seen in standard gd info is that gd recurs in about 2/3 (66%) of pregnancies. In the research literature, the results vary from 35% recurrence to 91% recurrence (see references), but the majority seem to run between 50-70% recurrence. So statistically, it is likely that your gd will recur.

However, if 2/3 of cases tend to recur, that also means that 1/3 of cases do NOT recur. And it is true----gd does not ALWAYS recur. There are women with gd in one pregnancy but not in any subsequent pregnancies (Kmom, for example!).  Some do not take any special actions yet their gd does not recur, while others with borderline cases may be able to prevent recurrence by being more proactive in between and during future pregnancies.  Or there are those whose gd does not recur in one subsequent pregnancy but might in another. However, although it is statistically likely that gd will recur, it is definitely NOT a certainty that it will, even in women with significant risk factors.  You cannot count on gd not recurring, but you are definitely not 'doomed' to recur.

Researchers have spent a lot of time trying to study characteristics of gd pregnancies in order to try and predict which women would have the greatest likelihood of recurrent gd. Different studies have found different factors to be important, but there do seem to be some constants. 

Maternal Age and Pregnancy Interval

Age is one of the strongest risk factors for gd, but one that is unavoidable. Since each time you have a subsequent pregnancy you are going to be older, the gd is more likely to recur simply because of age.  So one factor to consider is that your chances of avoiding or minimizing gd might be better if you had your next child sooner rather than many years later.  No one knows for sure if that will help, but it seems logical.  

On the other hand, spacing children too close together is a stress on the body (both physically and nutritionally).  Major et al., 1998, found that after controlling for multiple variables, a shorter interval (< or = 24 months) between pregnancies was more strongly related to recurrence of gd than many traditional risk factors.  While most other gd recurrence studies have either not studied this or  not found it to be significant (MacNeill 2001), it is possible that it might be significant for some women.  Because it was found to be a factor only in one study, women who are pregnant again within 2 years shouldn't be too alarmed, but if you are planning pregnancy spacing carefully, you might want to at least consider the possibility of 2 years between children.

Another argument against spacing pregnancies too closely is that it is not easy for some women to lose pregnancy weight gain completely between the pregnancies, and this might increase the chance of gd recurring (which is exactly what the authors hypothesized in the above study).  Furthermore, breastfeeding of the older child may be cut short if pregnancy occurs too soon (and the longer the child breastfeeds, the better it is for both of you), and raising children close in age is not easy.   

So while you might not want to wait ten years between pregnancies because of added risk from increasing age, neither should you rush the next one simply because of a concern over gd.  Your older child needs your full love and attention (and long-term breastfeeding if possible!) for the time being; don't rush things simply because of age pressure due to gd.   Find the age interval that works best for YOUR circumstances.

Weight Gain/Loss Between Pregnancies

It is clear from research that a significant weight gain between pregnancies means that gd is much more likely to recur. In the above study (Major et al., 1998), the other strongest risk factor for recurrence was a weight gain of 15 or more pounds between pregnancies. Because weight gain tends to increase insulin resistance, it may increase the chances of gd recurring. So it is very important between pregnancies to watch your weight and health habits.  Do NOT gain weight between pregnancies!

It does not follow automatically, however, that a weight loss between pregnancies will help prevent gd from recurring, though researchers continue to speculate that it might and do usually advise weight loss after a gd pregnancy (see above). Kmom has found no study that directly addressed whether weight loss would help prevent gd recurrence.  Peters (1996) indicated that in a very small subgroup of patients, a weight decrease between pregnancies seemed to result in fewer patients developing type II diabetes, but this was not the main focus of the study, and since the sample was so small conclusions are limited both for diabetes prognosis and gd recurrence.  In Pole and Dodds (1999) and MacNeill (2001), weight loss did NOT decrease the rate of gd, so there is limited and conflicting evidence on the subject.

No randomized study of weight loss on gd recurrence exists at this time (as far as Kmom has found), so no absolute conclusions can be drawn, but it is clear from the evidence that weight GAIN is harmful and heightens the chances of gd recurring.  It seems logical that weight loss might help, especially in the group of "responders" whose glucose tolerance is particularly weight-sensitive.  However, it should only be done sensibly, without drastically reducing intake during breastfeeding, and with plenty of time for weight stabilization and optimizing nutritional status before the next pregnancy.  As noted, for some women weight stability may be a better choice than weight loss; increasing exercise is probably the best route towards lessening insulin resistance and decreasing the chances for gd recurrence in these women.  

Ethnicity

Although there is less data on this, ethnicity may also play a role, since many studies on recurrence are done in the US on immigrant Latino populations, a group that tends to have very high rates of underlying diabetes in the population.  Since the majority of the studies have been done on Hispanics, the recurrence rate of 2 out of 3 quoted in most books and resources on gd may not apply to other groups.

Studies with primarily Latino populations do tend to have higher gd recurrence rates.  Spong (1998) found a 68% recurrence rate overall, while Major (1998) found a very similar 69% recurrence rate.  Peters (1996) found an even higher recurrence rate of 91%, with many of the women even progressing on to true diabetes (NIDDM) within a short period.  

Two USA studies with fairly strong African-American populations include Phillipson (1989) and Gaudier 1992 (as discussed in Moses 1996).  Phillipson found a 56% recurrence rate of gd, while Gaudier found a 52% recurrence rate of gd.  

Whites, especially those of primarily Northern or Western European heritage, tend to have the lowest rates of gd recurrence.  MacNeill (2001) found a recurrence rate of about 36% among mostly white Nova Scotians.  Studies on mostly Caucasian populations in Australia also found low rates of recurrence (about 35%) while studies of mixed populations in Australia found higher rates (around 70% overall, with birth in a non-English speaking country found to be a moderate risk factor for recurrence).  

Since gd does tend to occur most strongly in Latino and native populations (like Native Americans in the US and aborigines in Australia), pretty strongly in African-American, South Asian, East Asian, and Pacific Islander populations, and less strongly in Northern European populations, ethnicity probably also affects the rate of recurrence and severity of gd as well.  However, ethnic background should not be seen as a guarantee of either recurrence or avoidance, of course.  There are many other factors that may be more important.

Insulin Use

If you needed insulin in your previous pregnancy, does that mean that you will automatically have gd again next time?  The answer is that the majority of  (but not all!) women who needed insulin in their prior pregnancy will probably go on to have gd again in a subsequent pregnancy, and most will also need insulin again.  Some will have their gd recur earlier and more severely, so they should plan on getting early testing and using home monitoring even before gd diagnosis.  Careful and close monitoring should be the watchword for these mothers, but not over-reaction.

On the other hand, in some cases women who have needed insulin in a previous pregnancy do not go on to need it in a subsequent pregnancy.  And a few rare cases may not even have their gd recur at all, as noted in the Moses 1996 study cited above, where prior insulin use was not found to be a significant risk factor for recurrence of gd.  Sometimes a substantial change in diet and exercise can prevent not only the need for insulin but also prevent a subsequent case of gd altogether.  Being proactive in your health habits between pregnancies can really pay off!

But most studies do show that women who needed insulin in the prior gd pregnancy will probably go on to have gd again in a subsequent pregnancy.  Therefore these women should be extremely proactive about watching their diet and testing early in the next pregnancy.  

Other Factors

Other factors that may be associated with recurrence of gd in some studies include an early diagnosis of gd (before 24 weeks) in the previous pregnancy, older age, high fasting levels or very high test results on the Glucose Tolerance Test, a higher Body Mass Index (BMI, a measure of body size taking into account both height and weight), family history of diabetes, large baby size (9+ lbs.),  or the number of pregnancies a mother has had (parity).  

However, it's important to note that not all studies found that all of these factors were important.  In some studies, for example, high diagnostic levels on the Glucose Tolerance Test (GTT) was found to be a factor in whether or not gd will recur, yet in others, it was not found to be a significant factor at all.  In some studies, a macrosomic (big) baby from the gd pregnancy was predictive of the gd recurring, but in other studies it was not.  

It can be helpful to compare the studies to see which risk factors are found most consistently in the studies. Table One, below, compares several studies and which risk factors were found to be significant.  

Table One: Significant Risk Factors for GD Recurrence Analyzed By Study

Study Wt Gain Between Pregnancies Early Onset Insulin Age Macrosomia High BMI Parity Others Comments
Spong 1998      *  yes yes    *  yes  no   * high bG levels signf. mostly Hispanic, 68% recurrence
Major 1998 YES yes yes no no yes yes less than 2 yrs.between pregnancies significant mostly Hispanic, 69% recurrence
Moses 1996 yes   * no yes no   * yes  higher bG levels not significant mostly Caucasian, 35% recurrence
Foster-Powell 1998   yes   * YES YES   * yes   * GTT levels somewhat significant diverse popltn, non-Eng-speaking birth somewhat significant, 35% recurrence
Phillipson 1989 yes   *   *  *  yes yes  * ? diverse popltn, some African-Am 56% recurrence
Gaudier 1992   *   * yes   * yes yes  * high bG levels/high GTT signf. mostly African-Am popltn, 52% recurrence
MacNeill 2001 somewhat * * * YES YES * time between pregs. NOT significant mostly white population;  wt. gain between preg had higher gd recurrence but this did not reach statistical significance

* - not studied (or not specified in abstract)

CAPITAL LETTERS indicate the highest significance for recurrence, lower case letters a less-strong connection

 

Finally, there is limited data on the recurrence rate in several subsequent pregnancies.  MacNeill (2001) is one of the only studies to really address this.  In that study, women who had a gd pregnancy and then avoided gd in the next pregnancy had a recurrence rate of gd in the third pregnancy of only 21.5%----higher than in the average population, but still comparatively good odds.  On the other hand, women who had a gd pregnancy and went on to have gd recur in the next pregnancy had an almost 72% recurrence rate in the third pregnancy.   So if you've had gd twice, odds are you'll have it again-----but do notice that ~1/4 of those who had gd twice did manage to avoid it the third time!  You never know!

 

Tests To Get Before Trying To Conceive

Most gd guidelines indicate that you should be tested at a month or two postpartum to be sure your numbers have returned to normal after the pregnancy, since a small percentage of women remain diabetic after a gd pregnancy.  Although not every provider does the 6-8 weeks postpartum test, they really should. A full Glucose Tolerance Test (GTT) with a 75 gram load is the test recommended by the American Diabetes Association to establish normoglycemia after pregnancy. This non-pregnancy version of this test thankfully lasts only 2 hours and is only a 75 gram load instead of the 100g load used in pregnancy.  Other providers are satisfied with simply doing a fasting and/or postprandial measurement to be sure your numbers are now normal.

If you would like to have more kids in the future these periodic tests are especially important, since some researchers are now pushing doctors to automatically assume that you are truly diabetic in your next pregnancy unless you have PROOF that you returned to normoglycemia between pregnancies. So some kinds of blood sugar testing at about 2 months postpartum is critical in establishing whether you have returned to normal so that your next pregnancy is not treated as even more high-risk and intervention-prone.

Every year after the postpartum period, you should have an additional blood sugar test done at a lab. Although a few providers recommend yearly 75g GTTs, most consider this unnecessary. Most order instead a yearly fasting blood glucose (bG) test. This test should have a fasting period of 12 hours in order to get the most accurate result. Fasting results of 126 mg/dl and above on this test are considered indicative of overt diabetes, while fastings of 110-125 mg/dl are considered a borderline condition called "Impaired Glucose Intolerance", which often (but not always) goes on to become overt diabetes at a later point. (Note: Divide all figures by 18 in order to get the equivalent in non-USA standard measurements.)

Another test that many providers will order every year is the glycosylated hemoglobin test (also called in various circles the 'glycohemoglobin test', the 'HbA1c test', or the 'hemoglobin A1c test'). This test basically measures your overall glucose control over the last 2 months or so and is a better overall picture of your glucose tolerance than a fasting test, which simply shows a 'snapshot' of your bG on THAT particular day and does not reflect your post-meal readings either. Generally speaking, a lab result of about 4-6% is considered normal, BUT each lab has its own standards on this particular test and 'normal' can vary from one lab to the next, so be sure to ask for both your results AND the standards used by that particular lab to establish normoglycemia.

Although some insurance companies will not cover the yearly glycosylated hemoglobin test, if you are considering another child it would be a very good idea to be sure to have this test done periodically (it might be worth paying for it yourself). Studies have shown that elevations of the HbA1c results are linked to elevations of the rates of birth defects in diabetics, so knowing your HbA1c results can help you understand more thoroughly the state of your glucose tolerance before you conceive again. The least amount of birth defects have been shown to have occur with HbA1c results <5% so this is most optimal to have, but up to ~6% is still considered normal.  It would be a good idea to discuss your results and their implications with your provider in order to get a more accurate picture of your statistical chances. The risk of birth defects is small within normal limits; anything above normal limits should be discussed with your provider to clarify your particular risk levels.

If you have yearly lab tests and periodic home monitor tests, you should have a better data picture by which to make decisions. Shortly before you decide to start trying to conceive again, you might want to be retested again if a significant portion of the year has passed, just in case. However, if home monitor results are borderline or high at any time, be sure to have official lab tests done as well before starting to try. 

Also be sure to use a dependable form of birth control between pregnancies.  You do not want to conceive a child accidentally without knowing for sure that your blood sugar is indeed optimal beforehand.  If you become diabetic, you should not try to conceive before getting the blood sugars under control. The risks of birth defects and miscarriage are very real in true diabetes, and tend to occur most often with unplanned pregnancies, pregnancies with poor bG control, or pregnancies were the mother was unaware of her diabetes beforehand. If you are in the range of Impaired Glucose Tolerance, you must consult your provider for advice on what to do before trying to conceive, since your fastings (110+) are already over the range considered to need insulin in pregnancy (105 officially, less for some providers).

A special quandary exists for women who are borderline because the standards for pregnancy are so much more strict. Therefore, there is a "no man's land" where fastings or post-meal readings are considered borderline or too high for pregnancy (i.e. >105 fasting, >120 post-meal readings), yet by non-pregnancy standards, these are neither diabetic nor even quite Impaired Glucose Tolerance readings. And since the trend in gd treatment is stricter and stricter protocols, fastings between 95 and 105 are especially hard to know how to consider, since many providers these days recommend insulin for fastings over 95 in pregnancy.  In cases such as this, it is best to simply schedule a consultation with your provider, have the HbA1c test done for further information, and wait to see what your provider recommends before trying to conceive. Do not try to conceive in this situation without checking with a provider first!

Most gd moms will go on to have healthy pregnancies and babies in subsequent pregnancies, but it is best to be vigilant between pregnancies to be sure your levels stay normal. And if there is any doubt about your levels, it is best to consult an expert before trying to conceive again. They can advise you carefully about the specifics of your situation.

 

Tests During Pregnancy

Once you are pregnant, what can you expect in terms of testing? How often will they expect to do lab tests on you, and how much blood sugar testing on home monitors should you be doing?

One of the ways in which a subsequent pregnancy after gd differs from a normoglycemic pregnancy is in the timing of tests.  GD has been known to progress on to overt diabetes or states close to it even in small intervals between pregnancies. If your blood sugar levels are elevated just before or during conception, or during the fetus' first weeks of life, there is a high rate of birth defects and miscarriage. Therefore it is critical to have established that your levels were normal before conceiving (see above). 

Then, once you have conceived, it is extremely important to test in the first trimester to be sure the gd has not recurred early in the pregnancy. If early tests are still normal, testing between 24-28 weeks will then follow.  In addition, some providers will require testing in the third trimester if other tests are normal or borderline. Since most of the risks and poor outcomes associated with gd come from cases were the gd was severe, poorly controlled, early-onset, or from undiscovered pre-existing diabetes, it makes  sense to be more vigilant in testing in a subsequent pregnancy after gd.

Early Pregnancy Testing For GD

One important consideration is that when gd recurs, it often recurs earlier in the next pregnancy, and sometimes more severely.  Wein (1995) found that overall, all women with previous gd had a 5.1% rate of EARLY recurrent gd (i.e. diagnosed before week 24).  Furthermore, they found that certain groups had even more risk of early recurrence.  For example, women who used insulin in the previous pregnancy had 11x the risk for early recurrent gd, women of non-Northern European origin had 5.53x the risk, women who had had macrosomic (big) babies had 4x the risk, women with 'severe' gd had 3.52x the risk, and women over 30 had 2.27x the risk.   On the bright side, obesity, family history of diabetes, fasting blood sugars, and high parity (lots of kids) were not found to be risk factors for early recurrent gd in this particular study.  In other studies with other populations, of course, the relative strength of the various risk factors might be different, and in certain populations, the rate of early recurrent gd is probably much higher than 5.1%.  

So if in your first (or "index") gd pregnancy you were diagnosed at the usual time of about 28 weeks, it's possible that you may be found to have gd in the next pregnancy before 24 weeks. If you do test positive for gd in the first trimester or early in the second trimester, you probably will go on to need insulin before the pregnancy is done.  Some women are even found to have it early in the first trimester, raising the specter of birth defects and other problems.  So many providers are quite aggressive about testing for gd early in a subsequent pregnancy; most do it as soon as the next pregnancy is confirmed, or within a few weeks.  However, not all providers do early testing.

Later Testing For GD

If the test in the first trimester is negative for gd, the mother will be retested again in the second trimester, probably at the usual time of 26-28 weeks. Prime time for gd to occur is between 20-28 weeks, so some providers will test a bit earlier in the second trimester, but certainly by 28 weeks a former gd mom should be retested. 

If the second gd test is also negative, a third test between 32-36 weeks may also be ordered by some providers, since levels of progesterone (a strongly diabetogenic hormone) do not peak until around week 32.  If the first 2 tests were unequivocally negative and not even close, the 3rd trimester test can probably be omitted, but if the first 2 tests were even somewhat close, a third trimester test is probably justified. This is because insulin resistance continues to increase due to placental hormones that peak at about week 32 or so. Therefore, it sometimes does occur that women test negative at 28 weeks but retest positive later.

Testing Alternatives

Do you really have to take the full battery of gd tests 2 or 3 times in a subsequent pregnancy?  Can you use home monitoring instead? Are there alternatives to the traditional gd tests if they make you sick?  Many women with a history of gd question the reliability or validity of gd testing, or find them physically challenging and look for alternatives to traditional tests.  The answer is that there are alternatives to the usual testing protocols, but that some providers are more flexible about using these than others.  

Do you have to go through both the 50g one-hour screen and the 75g three-hour Glucose Tolerance Test (GTT) each trimester? It depends on your provider and your insurance. Most insurance companies insist on the 50g screen at least once in a subsequent pregnancy before going to the three-hour GTT. Although it's a pain if you do fail the one-hour test and have to go take yet another test, in the long run it's to your advantage to take at least one screen in the pregnancy. Some women, including Kmom, have found that they pass the one-hour test in a subsequent pregnancy, and using the screen saves them (and the insurance company) the time, trouble, and expense of the full GTT. However, if the first screen fails, you probably won't have to repeat the one-hour screen each trimester. After that, you will probably just take the full GTT each trimester as needed.

What about home monitoring? Officially, most insurance companies will not pay for you to have a home monitor until you have been officially diagnosed with gd. Therefore, you will not be doing any home monitoring to check and see how your levels are doing unless you are diagnosed or own your own monitor. This is a very foolish decision on the part of insurance companies ( the very ones that are supposed to be practicing 'preventive medicine'!), but the only way to get around it is to purchase your own home monitor. Kmom strongly suggests considering this, since it will continue to be of use to you after the pregnancy to be sure your bG remains normal postpartum and through life. 

However, if you cannot afford to own your own monitor, technically you do not have to do any extra testing or have to follow any special food plan until you 'fail' a GTT. Of course, it's a good idea to do all that ahead of time anyway, since it may help you eat more nutritiously, keep better control, and perhaps even avoid recurring gd. But following a gd food plan or doing home testing is not officially required until gd is diagnosed, even though it may be advantageous.

Although most providers test with the 1-hour glucose challenge test or go straight to the 3-hour GTT, some women experience a lot of nausea or sickness from these tests and would like an alternative to taking these tests multiple times during pregnancy.  Some providers are willing to work out compromises.  It is reasonable for them to need to have some testing to show whether or not gd has recurred and when, but some are willing to accept daily monitoring with a home glucose monitor instead, as long as the mother is already following a gd food plan and is being cautious.  This is the compromise Kmom worked out with her providers, and they felt it provided a much more accurate picture of what her blood sugar was really doing on a daily basis than dumping a ton of sugar into her system periodically and then testing.   She made sure that she found providers that were comfortable with this testing regimen rather than going through repeated GTTs because of her strong feelings on this.

Other women are able to work out other testing compromises, such as periodic fasting and postprandial tests at a lab instead of daily tests at home, or periodic testing at home (but not daily testing).  Some midwives are comfortable with substituting jellybeans for the glucola beverage and doing the one-hour glucose challenge that way; studies show women tolerate this test better than the standard glucola test.  If you are a woman who reacts poorly (nausea, shaking, fatigue, illness) to the standard gd glucola tests, these alternatives may make particular sense.  Women who tend towards low blood sugar episodes (hypoglycemics) may especially benefit from these alternatives.  For more information on using alternative tests and reference citations about them, see GD: Testing.

Further Testing Should GD Be Re-Diagnosed

If you are one of the ones whose gd recurs, your provider may wish to order monthly glycosylated hemoglobin (HbA1c) tests. Although these tests cannot be used to diagnose gd, they can be used to tell how good your control is. If you need insulin, you will quite likely have these tests performed monthly. If you do not need insulin but are diagnosed early in pregnancy, your provider may well decide to use these, since a high HbA1c level is more linked with birth defects and having gd early in pregnancy makes birth defects more of a concern. If you are diagnosed later in pregnancy and do not need insulin, your provider may or may not choose to use HbA1c tests--most do not, unless there is some question about your bG levels. As always however, each provider and insurance company has their own set of protocols, so your treatment may vary.

As with any gd pregnancy, extra testing to assure fetal well-being will be done at some point in pregnancy. However, when this is done is dependent on a number of variables. Some providers will order an early ultrasound if your gd is diagnosed early in pregnancy, to be sure everything looks normal. Otherwise, most will order the standard ultrasound at about 16-20 weeks or so. (Of course, you can decline any test, and you should not feel that you have to take any test just because of your gd status. Just be sure you are carefully informed before making decisions about accepting or declining any test.) 

AFP/Triple testing (alpha-fetoprotein testing, which screens for an elevated risk of neural tube defects or Down Syndrome), will also probably be encouraged, since diabetic pregnancies have a somewhat higher occurrence of neural tube defects or other problems (generally these problems are most often found with pre-existing diabetes or gd that has turned into diabetes between pregnancies). 

One note of caution about this is that AFP tests tend to have a higher number of 'false-positives' (both high and low) in women of size, and many providers consider them to be pretty inaccurate in women above 250 lbs. (see the section on Prenatal Testing and Larger Women for more information). Also, the cutoffs used are different when diabetes is present, gestational age needs to be absolutely accurate (if you have long cycles be sure this is accounted for!), and a precise maternal weight is very important as well, so be sure to discuss the implications of all of this variables carefully with your provider.  But do remember that if you get a 'positive' screen on the AFP test, the vast majority of 'positive' screens do not actually have problems associated with them----they are simply screens indicating a need for further testing.  Most results do not turn out to have significant problems associated with them.  

Regular assessment of the baby will be made once you reach the third trimester.  Exact timing depends on the circumstances of your own history.  If you have prior pregnancy losses, monitoring will probably begin between 28-32 weeks.  If you have high blood pressure, need insulin, have too much amniotic fluid (polyhydramnios), or other problems, monitoring will probably begin around week 32, give or take a little.  However, if you have good control with diet alone and no other real concerns, monitoring will probably begin anywhere from 36 weeks to term.  Tests commonly used include regular ultrasounds to estimate fetal weight (although keep in mind that these estimates are HIGHLY dubious and are only slightly more accurate than flipping a coin so their value is questionable), Non-Stress Tests (NSTs), and/or BioPhysical Profiles (BPPs).  

Near the end of pregnancy, many women experience a drop-off in insulin requirements/improvement in glucose tolerance.  Some providers feel that this indicates a decrease in placental function and will rush you towards delivery as a result, but more recently experts seem to see this as simply a reflection of the shift in hormones near the end of pregnancy as the body readies itself for birth.  Specifically, progesterone levels drop markedly to help the cervix start to soften and ripen for labor, and since progesterone is a highly diabetogenic hormone, this may explain the drop in insulin requirements/improvement in glucose tolerance common near term.  This is probably just a sign that the body is getting close to labor, but at this time, the significance of this change is not definitively known.  

 

Vaginal Birth After Cesarean or Repeat Cesarean

Some women who had difficult births/c-sections in their gd pregnancy will choose to have another child, but will face the decision of whether to choose a Vaginal Birth After Cesarean (VBAC) or an Elective Repeat Cesarean Section (ERCS).  Although the facts clearly show that vaginal birth/VBAC is safer for mother and baby in the vast majority of cases, it is often not an easy choice for a mother who has had a previously difficult birth.  

Emotionally, the mother may be torn between the two choices and may need more information about the risks and benefits of both VBAC and ERCS.  She may also need to examine her own emotions about her previous birth, her birthing desires and priorities, and her fears.  In addition, she may need to examine specifics about how gd can impact the choice of ERCS or VBAC Trial of Labor (TOL).  

Unfortunately, the data on VBAC vs. ERCS when gd is present is extremely limited.  Kmom knows of only one study thus far where the authors specifically studied only gd mothers and VBAC.  Instead, what little data there is on gd and VBACs is tucked into other, larger studies that usually focus on other subjects.   This data is very difficult to find, extract, and interpret, and limits what can be written authoritatively about the choice.  Despite this, the desire for VBAC information among women with previous gd is very strong, and Kmom has received many requests for a FAQ on gd and VBAC.  

Because of these requests and because of her own history of VBAC after gd, Kmom has written a preliminary GD and VBAC FAQ (based on the information and stories Kmom has so far), and this FAQ will be updated as further information and stories are accumulated.  

In the meantime, here is a summary of what Kmom has found thus far.  Because this FAQ is already quite  reference-intensive, no research (except Coleman 2001) will be extensively cited for this summary, but the main information comes from a number of bigger studies, including Jacobson and Cousins, 1989; Holt and Mueller, 1997; Naylor et al., 1996; Blackwell et al. 2000, and Keller et al., 1991.  More references are available in the FAQs on GD and VBACGD: Basic Treatment Protocol ReferencesVBAC After Multiple Cesareans, and Repeat Cesarean vs. Trial of Labor.  

Kmom is always searching for more data on the subject of gd and VBAC, both anecdotal and from the scientific literature.  She also particularly likes receiving gd VBAC birth stories.  Anyone who has further information or a GD VBAC birth story is requested to email it to Kmom along with permission to use the information or story.  Format suggestions are listed in the BBW Birth Stories section.  (Please don't use attachments when sending information or birth stories.)

Yes, Women Have Had VBACs With GD

Yes, gd VBACs are indeed possible, and have indeed occurred.  Several stories of gd VBACs can be found on this website under the section on GD: Birth Stories.  Some women think that their circumstances may preclude even thinking about a VBAC, but VBACs have occurred under all kinds of circumstances!

If you desire a VBAC strongly, no one can promise you a VBAC will happen for you, but it IS possible and it HAS happened before, even when women were told it was 'very unlikely'.   It may or may not be the right choice for you, but VBAC can and does happen under all kinds of circumstances, including when gd or diabetes is present.

VBAC vs. Repeat Cesarean: Factors to Consider

Although VBAC in general is better for both mother and baby, there are many factors to consider when making the VBAC vs. ERCS decision.  Only you can make the decision for what is best for you and your baby.  Although it is important to consult your provider, do remember that there is a very strong bias among most OBs towards ERCS in any woman with the 'diabetes' label attached.  Question assumptions, read up on a variety of viewpoints, sit down and honestly discover what your fears and concerns are about birth, and then decide how best to meet those needs or challenge those fears, and what would be best in your situation.  Although clearly Kmom's own bias is towards VBAC, if you decide that ERCS is what's right for you, then that decision is to be respected.  

This section is a quick comparison of the main benefits and risks of ERCS and a VBAC Trial of Labor (TOL) so that women can understand the main issues and advantages/disadvantages of each mode of birth.  Although most doctors emphasize only the possible risks associated with a TOL, there are significant risks associated with ERCS as well. The distorted recent media reports about the safety of VBAC is yet another example of this; only the risks of VBAC were reported, and no information on non-rupture risks of repeat cesareans were presented.  It is important to emphasize that neither elective repeat cesarean nor a trial of labor are without potential risks.   BOTH risks must be carefully weighed.

Please note that this section is a brief summary only. Again, because this particular FAQ on 'Preparing for a Subsequent Pregnancy' is already reference-intensive, the information in this particular section on VBAC vs. ERCS will only be summarized briefly and most references not cited.  A much more detailed discussion (with complete references) of this issue can be found in the ERCS vs. VBAC FAQ and the VBA2C FAQ. In addition, a detailed discussion of the New England Journal of Medicine (July 2001) study and the accompanying distorted editorial and media release is available at the International Cesarean Awareness Network's website, www.ican-online.org.  Kmom urges women considering VBAC or ERCS to read both sides of this controversy before making any birth decisions.

Physical Factors

In general, when VBAC results in vaginal birth, both the mother and the baby fare the best.  Research is very clear that successful VBAC (which generally occurs about 60-80% of the time) is definitely the most beneficial for both mother and baby, much more so than ERCS.  However, a trial of labor does not always result in a VBAC, and women who have a cesarean after a trial of labor tend to have more problems (like infection) than women who have an elective repeat cesarean.  And a few women in both groups will have an opening of their uterine scar, which is potentially very dangerous.  This is why choosing between ERCS and VBAC can be a dilemma for some.  

Unfortunately, the political and legal climate in this country has resulted in a VBAC backlash.  Many OBs are now openly discouraging VBACs, limiting them only to certain select groups, or finding subtle ways to dissuade women from them.  The recent editorial accompanying the NEJM study is a good example of this; the study actually mostly confirmed information that was already known about rupture risks, and the numbers and risk involved were not found to be excessive or above previously seen numbers.  However, the editorial accompanying the study blew the risk out of proportion, failed to consider the risks of repeat cesareans, and cleverly created anti-VBAC 'spin' in the media.  Suddenly the media was essentially reporting that VBAC was very dangerous and should not be attempted, when that was not the conclusion of the study at all.  As a result of this cleverly spun story, however, many more women are going to make an emotional choice for ERCS, thinking they are choosing the 'safe' route, and as a result be unknowingly subject to the risks of repeat cesareans.

Again, it is extremely important to note that the substantial risks of repeat cesareans are rarely mentioned when doctors discuss VBAC with mothers, and so-called 'VBAC consent forms' rarely make equal mention of the potential risks of cesareans.  Most often women are advised of the potential risks of VBAC without equal emphasis on the potential risks of cesareans, which are quite real too.  Both need to be considered in order to make an informed choice.  This section of this FAQ is an attempt to quickly summarize the potential risks of both.  However, please note that summaries tend to be simplistic; be sure to read up on these in more detail so you can make a truly well-informed choice.

In a nutshell, a VBAC Trial Of Labor (TOL) carries with it a small risk of uterine rupture.  In past research, a TOL did not seem to be associated with an increased risk for rupture, but recent research suggests that a TOL may increase the risk for rupture somewhat (although it is vitally important to note that even so, rupture is a very uncommon occurrence). Although usually caught in time and resolved without serious harm, in a worst-case scenario rupture could lead to hysterectomy, fetal injury or death, or theoretically, maternal death.  These risks are quite small, but should not be glossed over.  Uterine rupture is real and does sometimes happen, and if it is not taken care of in a timely manner, can result in serious problems or even death for mother and baby.  

A more common problem, however, is that if a woman has a trial of labor that ends in cesarean, mother and baby generally have a higher rate of infection than if the cesarean had been done electively.   Although this is treatable and rarely truly serious, infection always has the potential to be serious and should not be minimized either.  

Because of the risk of rupture (which may be slightly increased in a trial of labor) and the risk for infection if the VBAC TOL 'fails', some doctors have advocated abandoning VBACs.  This ignores the fact that the most benefit for the most people comes from promoting VBAC, simply because outcomes are best with successful VBAC and VBAC succeeds most of the time.

Elective Repeat Cesarean Section (ERCS) does not eliminate the risk for uterine rupture, although the risk may be somewhat lower with ERCS.  The way the risks are phrased may seem to imply that if you do not choose a VBAC trial of labor, you can eliminate any chance of uterine rupture, but this is not true.  Since it is the prior cesarean that causes the risk of rupture in subsequent pregnancy, both ERCS and VBAC TOL groups have a small but real risk for rupture.  Recent research seems to indicate that the rupture risk may be somewhat higher if labor occurs, though not all research shows this.  Certainly, the risk is highest when induction or augmentation agents are used during the labor process, and this tends to increase the rupture risks shown in most research.  At this time, we do not know the relative risks of rupture in ERCS groups vs. those women in spontaneous labor with NO labor augmentation or other drugs.  Thus it is difficult to definitely compare the risk of rupture adequately.

ERCS is also associated with other serious risks, although these are vastly underemphasized.  A repeat cesarean  strongly increases the risk of bleeding problems for the mother, breathing problems for the baby, has a higher rate of rehospitalization for complications postpartum, may cause significant scarring and adhesions internally, and may also increase the risk for ectopic pregnancy, miscarriage, infertility, appendicitis, and gallbladder problems. One greatly underestimated risk is that cesareans strongly increase the risk for placental abnormalities in future pregnancies, which could injure and even kill those babies. Because of the placental abnormalities associated with repeat cesareans, the risk for hysterectomy is actually greater with ERCS than it is with VBAC TOL. And in very rare cases, these placental abnormalities can lead to maternal death.   The fact is that the more repeat cesareans you have, the more likely placental abnormalities are to occur.  If women want more children in the future, this future risk must also be factored in too, yet it is rarely even mentioned.

Even if your recovery from ERCS is uneventful, it is still more difficult than recovery from normal vaginal birth.  While most women cope anyhow, it's not the easiest way to begin parenting.  VBAC activists point out that if you were adopting a baby instead, you wouldn't choose to have major surgery on the day you were to receive your new baby.  And if you have older children who also need your attention, imagine taking care of them AND your newborn while recovering from major surgery! You could manage if you had to, but it's certainly not the most stress-free way to begin.  Cesareans are not just stressful physically and emotionally, but they can also stress early parenting and family life.  

Summary of Relative Risks of VBAC vs. ERCS

In summary, successful VBAC is clearly associated with the best overall outcomes for mother and baby.  However, those who have a TOL and then another cesarean are at increased risk for infection.  VBAC may also raise somewhat a woman's risk for uterine rupture, although with more conservative use of induction and augmentation, the risk is likely to be lowered and may become more equalized.  However, with judicious use of induction, the risk of rupture is not excessive and outcome is usually reasonable.  Induction and augmentation should be avoided whenever possible in VBAC to minimize risk, but if truly necessary they may be reasonably chosen if done judiciously.  On those occasions when rupture does occur, it usually does not result in catastrophic outcome, but the risk is not negligible and can result in injury or death.  However, the vast majority of women who chose a TOL have healthy babies, whether they have a VBAC or not, and the majority of women who try for a VBAC do have one.  

The best response to these risks may not be to avoid a trial of labor, but to be more aggressive about avoiding protocols and drugs that increase rupture risk, to respond more quickly to rupture if it occurs, to minimize procedures that are known to increase infection risk, to watch carefully for problems if a TOL cesarean does occur, and to study ways to raise  the rate of VBAC success so that more women receive the better outcomes associated with successful VBAC.  

Elective Repeat Cesarean Sections also clearly present substantial potential risks which often tend to be glossed over.  Uterine rupture is still possible even if a TOL is not chosen; choosing an ERCS does not 'guarantee' anything. Fetal respiratory problems, both temporary and long-lasting, are clearly much higher with elective cesareans.  Maternal morbidity (infections, hemorrhaging, postpartum problems, scarring and adhesions, long-term pain, etc.) is also clearly higher with ERCS.  But the risks of multiple cesareans are most clear if a woman desires more children; each successive repeat cesarean raises the risk of abnormal placental implantation or abruption in the next pregnancy, and this can put the lives of both baby and mother at risk in the future.  

On the other hand, great strides have been made over the years in making cesareans (especially elective ones) safer and less traumatic, and there are many things that can be done to minimize infections and other morbidity.   In addition, although the risks for placental abruption or other abnormalities are definitely increased, the majority of women who have multiple repeat cesareans do have healthy pregnancies and healthy babies.  

In other words, the risks from both TOL and ERCS do have to be kept in perspective.  Both have potential for catastrophic consequences, and these risks are real and must not be regarded lightly.  But even so, the actual occurrence of problems associated with either VBAC TOL or ERCS are low, and the vast majority of women who chose either a VBAC or an ERCS will be just fine either way.  

GD Factors

For the most part, gd should not greatly influence the choice of TOL vs. ERCS.  However, there are a few pertinent facts that may need to be considered.  

First, it is clear that most OBs have a lower threshold for surgical intervention when diabetes/gd is present.  This has been shown in a number of studies, although there are certainly doctors who are less interventive.  Although rates will vary from provider to provider, the c/s rate for true diabetics is usually at least 50%, and can go as high as 80-90% in some studies.  In gd, the c/s rate generally averages between 25-35%---lower, but still higher than the average in the rest of the population (which is also too high).  Thus, most OBs' inclination when they see a woman with a prior cesarean and gd is to schedule another cesarean.  This ingrained predisposition may be difficult to overcome, and the woman who strongly desires a VBAC may have to search hard for a truly supportive provider. 

Second, the risk for shoulder dystocia is higher when diabetes or gd is present.  Therefore, most OBs will require an ERCS if the baby is estimated to be >4500 grams (9 lbs., 14 oz.).  Some will require an ERCS if the estimated fetal weight is above 4000 grams (8 lbs., 13 oz.).  This will cause a lot of unnecessary cesareans because of the high inaccuracy of ultrasound estimations of fetal weight, but many OBs are so wary that they will use that 4000g cutoff anyhow.  So while a provider may be willing to agree to a trial of labor, they may do so only on the condition that the baby be estimated to be of average size.  Since estimated fetal weights are only slightly more accurate than a toss of the coin, this will mean that a lot of women will be denied a trial of labor at the last minute, many of them unnecessarily. And since large mothers tend to measure larger in fundal height, larger women will probably be particularly impacted by this.  

Third, on average, between 40-60% of gd mothers have their labors induced before term.  Although data is very limited and needs to be confirmed, some research does suggest that early induction may lower the rate of shoulder dystocia in gd, especially in insulin-dependent women (it doesn't in normoglycemic women, but at least one study found that it did in insulin-dependent gd moms).  Because of this, most doctors firmly believe that induction is 'necessary' when gd is present, which is debatable.  However, since recent research shows that induction is a strong risk factor for uterine rupture, now doctors are even more inclined to choose ERCS for gd mothers.  In a nutshell, they feel that early induction is the 'best' way to avoid shoulder dystocia, but induction raises the risk for uterine rupture, so rather than await spontaneous labor and try to minimize risks for shoulder dystocia, they usually choose ERCS.  This dilemma will be a difficult one for any gd mom who wishes a VBAC TOL, especially if she is larger or has a history or bigger babies.

Finally, if for whatever reason an ERCS is needed or chosen, it is important not to schedule the surgery too early.  The current trend is to do elective cesareans earlier and earlier, and many doctors schedule them routinely at about 38 weeks.  However, because of the risk of temporary or long-lasting fetal breathing problems, it may be better to schedule an elective cesarean later rather than earlier, so the baby is more ready to handle breathing on its own.  This is especially important if the mother has longer menstrual cycles, irregular cycles, or if there is any question about the due date.  Research suggests that at least some cases of Respiratory Distress Syndrome may be able to be avoided simply by delaying an elective cesarean a week or more.  

Since fetal lung maturity may be even more of an issue for women with gd (especially difficult-to-control gd), gd mothers who need or who choose ERCS should probably schedule for 39 weeks or later.  If ERCS becomes medically necessary earlier, gd mothers should consider scheduling an amniocentesis to determine fetal lung maturity.  Determining fetal lung maturity is always important for a gd pregnancy that may be delivered before 38 weeks; it is somewhat debatable whether this amnio is necessary if induction is chosen at 38 weeks.  However, because of the extra risks for respiratory distress that accompany elective cesarean, it is Kmom's opinion that any elective cesarean at 38 weeks should always have confirmation of fetal lung maturity before proceeding.  

Also keep in mind that babies born a bit earlier tend to have more hypoglycemia problems (which gd babies are already at risk for anyhow), may have a less efficient suck, and have less mature livers (predisposing to more jaundice problems).  All of this may add up to sabotage breastfeeding efforts.  So unless there is a truly compelling medical reason for scheduling  surgery earlier, it is Kmom's opinion that ERCS should probably not take place any earlier than 39 weeks, and preferably 40.  

Emotional Factors

Some women who have had difficult births or painful inductions in the past simply elect another c-section from the beginning rather than possibly face another induction or difficult birth. For some women, this might be the right choice, but that decision should never be made lightly or without full awareness of the issues involved. If, after careful consideration, you feel that it is the right decision for you, then that's a decision that should be respected.  However, don't be scared into an Elective Repeat Cesarean Section (ERCS) simply because your previous birth was long or hard.  Changes in provider and in the choices made around the birth can create a completely different birthing scenario from your last birth.  This birth does not have to be the same!

Other women strongly desire a normal vaginal birth and choose to pursue a VBAC but find that there are emotional issues that may impact this choice.  For example, many VBAC moms find the lack of 'guaranteed' results unsettling, or may find it hard to believe in their bodies' ability to give birth normally, especially if their gd diagnosis shook their faith in themselves.  They may find that their friends or family pressure them into the 'convenience' of an elective c/s (convenient for whom?), or think they are crazy for wanting to birth normally.  Many women who choose a VBAC find that not knowing how it will all turn out is the most difficult thing of all.  Learning to live with that and finding a way to avoid a 'success/failure' attitude towards birth is an important part of the VBAC journey.  

What both groups should probably aim for is what birth activists have coined "Empowered Birth After Cesarean" (EBAC).  An EBAC happens when a woman takes control and finds a way to make the next birth more family-friendly and more empowering than before, whether that's by cesarean or by vaginal birth.  The way the baby arrives is still meaningful, but the most important thing is finding a way to make a BETTER BIRTH EXPERIENCE, whatever that means to you.  It can be helpful to really sit down and think about what would make this birth a better experience, and what you need to do to help make that happen.  

GD and VBAC Studies

As noted, the main study examined here is the Coleman et al. study from May of 2001, as published in the American Journal of Obstetrics and Gynecology.  This is the only study Kmom has found thus far to specifically examine ONLY gd and VBACs.  Hopefully, many more will start emerging soon.

This study examined a trial of labor (TOL) in 156 women with gd and a prior cesarean, with 272 normoglycemic controls who had had a prior cesarean.  All the gd moms were seen by the obstetric endocrine clinic (specialists).  The women with gd were induced almost twice as often; the gd mothers had a 38.5% induction rate vs. a 22.4% rate for the controls.  There were no ruptures in the gd TOL group; there were 2 ruptures in the controls (0.7% rupture rate).  

The following table summarizes the overall VBAC totals for each group, uncontrolled for induction.

Table II:  Coleman et al. (2001) GD and VBAC study - Overall Results

  C/S after TOL VBAC rate Rupture Rate
GD                  (n=156) 35.9% 64.1% 0.0%
Controls        (n=272) 22.8% 77.2% 0.7%

The VBAC rate was somewhat lower for the gd group (64% vs. 77%), a fact the study strongly emphasizes, while conveniently forgetting to mention that even so, about 2 of every 3 gd moms who tried did end up having a VBAC.  In fact, if about 2/3 of gd moms who try will end up having a VBAC, then it is worth 'allowing', given VBAC's lower overall morbidity and cost.   Even if the overall 'success' rate is lower, there is still more than enough success to make it worthwhile.

One concern of many providers is that a VBAC trial of labor might increase the rate of shoulder dystocia, the complication that doctors obsess about with gd.  In this study, there was no statistical difference between groups in shoulder dystocia, although the rate was just slightly higher in the gd group.  However, it is important to note that gd women in the study were more than twice as likely to have forceps or vacuum extraction used in their VBAC; the excuse used is that the infants of the gd pregnancies were slightly larger on average.  Yet this is a foolish practice, as studies have shown that using forceps or vacuum extractor quadruples the rate of shoulder dystocia, and especially so if the baby is larger.  In fact, it is likely that the shoulder dystocia rate with gd in this study could have been much lower by less use of forceps/vacuum extractor. If OBs are truly interested in lowering the rate of shoulder dystocia, they should focus more on avoiding operative interventions like forceps and vacuum extractor rather than forbidding a trial of labor.  

Because the gd mothers were induced at almost twice the rate of controls, the authors wondered how the VBAC rate of the spontaneous labor and induction groups would vary.  And indeed, this subanalysis provides some provocative information.  

Table III:  Coleman et al. (2001) - Spontaneous Vs. Induced Labor VBAC Rates

  Spontaneous Labor VBAC Spontaneous Labor c/s rate Induced Labor VBAC rate Induced Labor c/s rate
GD group 81.3% VBAC rate 18.7% TOL c/s rate 36.7% VBAC rate 63.3% TOL c/s rate
Controls 90.5% VBAC rate 9.5% TOL c/s rate 31.1% VBAC rate 68.9% TOL c/s rate

This table shows that awaiting spontaneous labor greatly improves the VBAC rate in both gd moms and normoglycemic women.  An 81% gd VBAC rate is excellent, and means that more than 3 out of 4 gd moms who labored spontaneously ended up having a VBAC.  Since most VBAC studies average between 60-80% success rates, this is good news.  

The VBAC rate in the induction group points out how strongly induction impacts VBAC success; only 36.7% of gd moms who were induced had a VBAC, while the rate was even lower (31.1%!) for the normoglycemic group who were induced.  Although these results need to be duplicated, it does seem to argue strongly for the value of awaiting spontaneous labor whenever possible in a trial of labor.  

Critics will note that the VBAC rate for spontaneously laboring gd moms was still lower (81%) than in the normoglycemic group with spontaneous labor (90.5%).  And it is true that the overall success rate and the spontaneous labor success rate was lower in gd moms.  However, this may simply reflect a lower threshold of intervention when the gd label is present, a strong tendency noted in a number of other gd studies (and remember that the gd patients here were all treated by specialists, which often tends to increase the c/s rate).  The authors do briefly note the possibility of the VBAC rate being lower because of 'physician preference',  and they also note that other factors were not able to be controlled for (such as history of prior vaginal births in either group, which tends to raise VBAC success rates).  This is an important point which should be investigated in future studies.

Furthermore, they note that they were not able to compare neonatal morbidity between gd and normoglycemic groups because of database limitations.  It would be important to compare how gd babies of successful VBACs vs. failed VBACs vs. elective repeat cesareans do, and how their results compare to those of comparable normoglycemic pregnancy babies.  Also, because uterine rupture and shoulder dystocia are relatively rare events, the authors note that their power to detect differences between these groups in a study this size is limited.  Hopefully, future studies will address these issues more thoroughly.

The results of this study should actually encourage VBACs for gd moms, since the majority of gd moms who tried ended up having a VBAC, and the VBAC rates when moms labored spontaneously were especially strong (81%).  However, the study's authors consistently opt to emphasize the most negative view of the issue in their abstract, worded in such a way as to discourage VBAC attempts with gd. They note gloomily that the mothers with gd "were less likely to have a successful trial of labor," and that women with gd should be "appropriately counseled about the risk of attempting a trial of labor after previous cesarean delivery."  

This is typical gloom and doom OB reporting, especially in this age of VBAC backlash  The results are reported by the 'failure' rate (those who had a c/s after a trial of labor), instead of by the 'success' rate (those who had a VBAC), so that it's conveniently not obvious that the majority of gd moms had a VBAC anyhow.  They also fail to emphasize in the abstract that promoting spontaneous labor raised the VBAC rate to more than 80%, while inducing a woman with a prior cesarean (whether the woman had gd or not) led to abysmally low VBAC rates all around.  Instead, the way the authors summarized their results will lead the casual reader to conclude that there's no point in trying for a VBAC if a woman has gd, when in fact chances for VBAC are good, especially if one awaits spontaneous labor.   

The authors do conclude at the end of the study that, "Women with gestational diabetes should be allowed a trial of labor if they fulfill the same clinical requirements as women without diabetes."  However, they then qualify the statement by noting that, "Although most women with gestational diabetes with a history of cesarean delivery will undergo repeat operations, some carefully selected women can have a successful VBAC.  Further studies with larger sample sizes are needed to better define the morbidity associated with VBAC in this important patient population."   Faint and ambivalent encouragement, but at least some is better than none.

Barriers to VBAC

The biggest barrier to gd VBACs seems to be getting a 'trial of labor' (the opportunity to labor and 'try' birthing vaginally, instead of simply going straight to ERCS).  Research clearly shows that many providers have a strong predisposition towards cesarean delivery when the 'gd' label is present, and what research there is on gd and VBAC shows that gd moms are 'permitted' fewer trials of labor (TOL) than non-gd mothers with previous cesareans.  The hardest part of pursuing a VBAC is probably finding a provider that will encourage a trial of labor instead of an ERCS.  

Even if you can find a provider open to the idea of a VBAC when gd is present, even harder is finding one that is TRULY supportive of VBAC.  Research clearly shows that the rate of VBAC among nondiabetic women differs greatly between providers and even between institutions.  Some hospitals have only a 40-50% VBAC TOL success rate, while others have 80-90% success rates.  Some providers have a  50% total cesarean rate, while other providers have a 10% cesarean rate (and some even less!).   Other providers say that they are supportive of 'trying' for VBAC, but when the woman is close to term, finds a million reasons why trying 'would be too dangerous' or 'would never succeed'.  

Clearly, if you desire to have a VBAC, choice of provider is absolutely critical.  Many VBAC advocates tell women to find a provider who is not lukewarm about VBAC and who believes in your ability to VBAC even more than you do.  Find one that has a low overall c/s rate, one that does not automatically induce most gd moms, one who does not unduly dwell on the risks of VBAC, and one that has a good success rate with VBACs (70% or more).  More hints on finding a VBAC-friendly provider can be found at the International Cesarean Awareness Network's website, www.ican-online.org.  

Finally, probably the most difficult obstacle to overcome in getting a VBAC is the medical tradition of inducing gd moms.  As noted above, studies show that approximately 40-60% of gd moms have their labors induced (as compared to about 20% of the normoglycemic population). Research clearly shows that induction strongly lowers the chances for VBACs.  Induction also is linked with increased rates of uterine rupture.  However, because some limited research seems to show that inducing early may reduce the rate of shoulder dystocia in insulin-dependent gd moms (and because traditionally diabetic moms have always been induced early), it is very difficult to convince providers into 'permitting' a spontaneous labor.  Yet this probably allows the gd mom their best chance at VBAC.  

If your provider insists on an induction or if an induction becomes truly necessary,  research shows that you are at more risk for rupture BUT that this risk probably does not become unreasonable if the induction is done judiciously.  Recent research indicates that uterine rupture rates are greatest when multiple induction agents or high dosages are used, so it seems sensible to avoid using more than one method of induction in a short period of time (i.e., don't use prostaglandin gels in multiple doses, proceeding straight to high doses of pitocin shortly afterwards).   Try to use one method of induction only, use minimal dosages whenever possible, avoid multiple doses or spread multiple doses out over a greater time period, and wait a couple of days before trying additional methods like pitocin.  Also absolutely avoid use of Cytotec (misoprostol), which has been implicated in particularly high rates of uterine rupture during VBACs.  

If you must be induced, you might also want to avoid letting them break your waters during the induction.  This offers several possible advantages.  If your waters are not broken, you can elect to stop the induction and try again in a few days (serial induction), which may increase the chances of a successful induction.  (But again, try to spread it out time-wise.)  If your baby is not optimally positioned, breaking the waters commits the baby to that less-than-optimal position and makes it hard for baby to turn, which often leads to long hard labors and lots of intervention.  Avoiding breaking the waters often gives a malpositioned baby the 'cushion' it needs to resolve its position.  

Finally, because infection is one of the risks of a c/s after a 'failed' (TOL), and because lots of vaginal exams (especially after the waters are broken) are a known risk for infection, you may be able to decrease your risk for infection by avoiding breaking the waters.  At best, the only advantage of breaking the waters early is to shorten labor by about an hour; at worst, it can lead to problems like increased labor pain, malposition, and infection.  So it seems logical to avoid breaking the waters during an induction.  Because this procedure is an ingrained part of most hospital's induction protocol, however, you may have to be quite assertive about avoiding it.

Finally, if you must be induced, you can probably increase the chances of vaginal birth by hiring a doula (professional labor support).  Research has shown that having a doula present can lower the c/s rate by as much as 50% in some cases.  Although very little research exists on doulas and induction, one small study showed that having a doula present during an induction cut the c/s rate from 63% to 20%.  Even if you are not induced, having a doula present for labor support in addition to your partner can lower the chances for cesarean significantly.  For more information on finding a doula, see www.dona.com

Finding a VBAC-Friendly Provider

It is almost always a good idea to switch providers from the provider group who did the cesarean at your last birth.  Although they may be perfectly nice and supportive of VBACs on the surface, unconsciously you associate them with your prior birth, and it is often best to change providers as part of  trying to change birth patterns.   Certainly, sometimes you can keep the same provider and do just fine, but most women find  it is best to change providers (and even birth locations) when considering a VBAC.  Find as many ways as you can to make this birth a NEW experience, both in obvious ways and in subtle ones.  You'd be surprised at how much difference that can make psychologically. 

Be aware that while that search for a new provider may be very worthwhile and empowering, it may be hard work.  Because an elective cesarean operation is easier to work into an office schedule, because monitoring labor and birth is more time-consuming than a brief operation, and because OBs are surgeons who are far more trained in surgery than in attending normal births, many OBs are more comfortable with and strongly promote a repeat cesarean rather than encouraging women to go for a VBAC.  Also, although the American College of Obstetricians and Gynecologists (ACOG) still promotes VBAC trials of labor, there has been a recent backlash against VBAC and OBs are now required to spend much more time monitoring and attending a VBAC labor, which makes office hours difficult.  So many OBs who have promoted VBACs in the past are more reluctant to promote it as strongly now.  

Midwives as a group are much more VBAC-friendly than OBs.  Statistically, you are 3x more likely to have a VBAC with a midwife than with an OB.  Therefore, you may want to start your search by interviewing several midwives.  However, protocols differ from state to state and provider group to provider group.  Because of the current VBAC backlash, some doctors' groups have taken advantage of the situation to prevent midwives in some states from attending VBACs, or keep midwives in their practices from taking VBAC cases.  On the other hand, midwives in other areas or groups may have NO problem attending a VBAC mom.  Ask around in your area, and be sure to investigate all possibilities thoroughly.  Many a mom (including Kmom) has been told that a midwife is not possible for her, only to find out later that it was.  Be willing to travel, and check out all possibilities.  Even when you think all doors are closed, another possibility often appears if you keep looking.   

Family doctors are another possible choice.  Although not all do obstetrics, many do.  Research shows that they have lower c/s rates in gd than most OBs do, and often are more liberal about VBACs as well.  If a midwife is not possible in your area, then try searching for a family doctor.  However, no matter what the title of your provider is, it is VITAL that you carefully check into their VBAC policies and underlying beliefs.  Don't take for granted that a certain title ensures VBAC-friendly beliefs and practices!

Even among providers who say they are supportive of VBAC, many sabotage the process both overtly and subtly.  Many women hoping for a VBAC have reported in VBAC support groups that their providers did a "bait and switch" technique near the end of their pregnancies when the women were less likely to switch providers and more emotionally vulnerable to discouragement.  Suddenly, a million reasons were found why a VBAC 'shouldn't be attempted' or 'wouldn't succeed' or 'would be too dangerous'.  The striking frequency of this change of tune suggests that many providers tell women what they want to hear at first, but change the tune as term approaches, either due to a lack of true commitment to VBAC or due to their own exaggerated fears. It may not be a conscious thing, but it is quite common.  'Listening in' on OB email lists reveals just how common this practice is.

Even when a provider seems supportive of VBAC on the surface, he/she may present many subtle barriers to VBAC.  For example, in the past many providers have required early induction to "increase the chance for VBAC", despite the research showing that it does just the opposite. Other providers place so many strictures on VBAC labors (must dilate 1 cm per hour, must not go past term, baby must be under 8 lbs., labor must not last more than 'x' hours, mother must have continuous monitoring from very early in labor and must be flat on back in bed, etc.)  that the baby practically must fall out in order to get a vaginal birth.  This is one of the most insidious barriers to VBAC, and the mother must be careful to ask detailed questions about different scenarios in order to try to discover whether the provider really is TRULY supportive of VBAC or is just paying lip service to it.   Again, more information on finding a VBAC-Friendly Provider can be found at www.ican-online.org

Hints to Increase Your Chances for a VBAC

In order to increase your chances for a VBAC, you should consider the following.  Please note that these choices may not be appropriate for all gd moms; each person's individual medical status and needs may dictate different choices.  These are simply Kmom's opinions of possibilities to consider that would probably increase the chance of VBAC success.

  1. Hire a Midwife for your care - Research shows that midwives have much lower c-section rates across the board.  Part of this is because they take less high-risk cases, but even when only low-risk cases are compared, midwives have much lower c/s rates in general.  In gd cases, midwives and family doctors generally have about half the rate of c-sections that OBs do.  And research shows that you are about 3x more likely to have a VBAC with a midwife than with a doctor. 
  2. Hire a Doula to help you in your labor - Research shows that doulas (professional labor assistants) lower the c/s rate strongly, both in spontaneous labors and in inductions.  Although no research specifically addresses doulas and VBAC success rates, it is quite likely that  success rates are much higher with a doula assisting your partner for your labor support.  
  3. Try to avoid epidurals and pain medications if possible - Although not always true, natural childbirth does tend to end in vaginal birth more often than those using lots of pain meds.  Beware the studies that claim that epidurals don't increase the c/s rate; they are usually comparing epidural use to the use of other pain medications, NOT the c/s rates of epidurals vs. natural childbirth methods.  However, an epidural or pain medication is not necessarily ruled out for VBAC moms; in certain situations it can actually help.  Try to avoid an automatic epidural if possible, but if you need or choose to have an epidural, try to wait until after 4-5 cm dilation and until baby is well-engaged in your pelvis, which tends to decrease the c/s risk.
  4. Try to avoid inductions if possible - Research shows that inducing labor sharply reduces the VBAC success rate in most studies, although even in induction some VBACs still succeed.  New research also shows an increased risk of uterine rupture when labor is induced, so it's best to avoid induction whenever possible.  However, if immediate delivery does become truly necessary, careful use of induction drugs and techniques can still occur, if used judiciously.  Using too many induction methods together (i.e., prostaglandin gel and then pitocin) seems to particularly increase the danger of rupture, so beware overloading with too many types of induction agents at once, or mega-doses of any one induction agent.
  5. Investigate fetal malpositions and how to prevent them - Many previous cesareans are actually caused by a subtly malpositioned baby, a problem vastly under-recognized in the obstetric community.  Oftentimes, fetal malposition can be prevented or corrected, which anecdotally many women have reported as helping them towards their VBAC.  Read the FAQ Kmom has written on Malpositions, and find a provider that will help you avoid or correct a malposition proactively.  Also read the books listed in the references on it.
  6. Prepare emotionally and intellectually - Take another childbirth class, one that has lots of VBAC information or an emphasis on emotional preparation for birth, such as Birth Works ( www.birthworks.org), Birthing From Within ( www.birthingfromwithin.com), or Hypnobirthing ( www.hypnobirthing.com).  Take time to journal about your feelings from the first birth, and work through your fears and hopes for this birth.  Inform yourself with books on VBAC preparation like Silent Knife by Nancy Wainer Cohen, The VBAC Companion by Diana Korte, Natural Childbirth After Cesarean by Crawford and Walters, The Thinking Woman's Guide to a Better Birth by Henci Goer, or Birth After Cesarean  by Dr. Bruce Flamm.  
  7. Use visualization and guided imagery to 'see' a vaginal birth for yourself - Relaxation and visualization can be very important tools to help you imagine a normal birth for yourself and make it happen.  Many women who have had cesareans realize that they have a difficult time imagining themselves actually giving birth.  Watch empowering videos like "Birth in the Squatting Position" that help you visualize what normal birth looks like, and then imagine yourself giving birth vaginally.  Utilize all your senses in your visualization.  Also, many women find that listening to birth affirmations and relaxation tapes just before sleep are very helpful.  Kmom has a list of where to get these in her websection on Great VBAC Resources.

To review, VBAC is indeed possible, even if gd recurs.  For some women, an ERCS may be the best choice, but for most women a VBAC is absolutely possible and usually advantageous.  Having gd may impact some of the decisions that influence VBAC; the dilemma over whether to induce is probably the most difficult issue women with gd face.  However, whatever a woman chooses, it is important to do so from a fully informed stance, and not based on media 'spin' or misconceptions about VBAC and ERCS.  Neither choice is risk-free, but while both can be associated with serious potential risks, the actual rate of problems with either choice is low, and the vast majority of women who choose either VBAC or ERCS do just fine.  

Not all women who have had a past cesarean found the experience unpleasant; although the emphasis here has been on addressing the needs of women who have had a difficult birth (usually a difficult induction leading to a cesarean), some women with gd are perfectly happy with their cesareans.  While some of these women will choose another cesarean, some do choose VBAC; having had a 'good cesarean' doesn't preclude wanting a normal birth.  However, many women with gd have communicated to Kmom how interventive and difficult their past births were, and how much they desire to avoid a similar situation.  They felt robbed of the joy of birth by their cesarean, and drained of the energy to enjoy their babies.  Many found the recovery difficult or longer-lasting than they expected.  These are the women who often want a VBAC most strongly.   

If you have had a difficult birth, rest assured that YOUR NEXT BIRTH CAN BE DIFFERENT if you wish.  Start by visualizing an ideal birth and what that entails for you.  Consider how emotional factors might have impacted your past birth and affected your choices, and how you can work through those issues.  Get your medical records and find out as much as you can about your prior birth(s).  Inform yourself about important VBAC issues.  Search carefully for a provider who really listens to you and will honestly try to help you meet your birthing needs.  Examine your fears---how can you best challenge or resolve them?  How can you proactively work towards a better birth?  Make a plan of things you can do to change and improve your experience, and then do them.  

Whether you opt for a family-friendly cesarean or a family-friendly VBAC, aim for an Empowered Birth After Cesarean.  Brainstorm your plan for making a better birth experience for you and for your baby, then follow through!  'GD' does not have to mean an unempowering or unpleasant birth experience. You can have a better birth, whatever that means to you.  Dig deep inside, learn more about what is important to you in birthing, discover what kind of birth you want to give to your baby, then stand up for yourself and your baby and find a way to work towards that.  Work for a better birth----your baby deserves it, and so do you! 

 

Summary

It is clear from the gd recurrence studies that gd probably CAN be prevented from recurring in some women.  Usually these are the women with more borderline cases, those who respond strongly to changes in diet, exercise, or weight loss, or those in whom the initial diagnosis might have been questionable.  Occasionally gd can be prevented from recurring even in women whose gd was stronger or who needed insulin, but this is more unusual.  

In other women, genetic or hormonal factors are too strong and gd probably cannot be prevented.  For these women, the goal is to minimize the gd as much as possible so as to have the best possible outcome, and hopefully, less intervention along the way.  

The Role of Nutrition and Exercise

Many midwives believe that gd can be prevented in many or even most women.  Although hard data is lacking on this (mostly because it has not been studied), anecdotal evidence seems to suggest the prevention is possible for at least some women.  The emphasis on excellent nutrition and exercise in many midwifery practices may help this.

Because most midwives (especially direct-entry or homebirth midwives) emphasize nutrition much more strongly than doctors, they feel that they reduce the incidence of complications such as pre-eclampsia and gestational diabetes.   They point to their clientele to show MUCH lower rates of gd and pre-eclampsia than most other providers experience.  Some of this is undoubtedly pre-selection bias----the women who are going to be more at-risk for complications are probably going to be seeing doctors, and the women who tend to gravitate towards alternative care tend to be more interested in and willing to work with nutrition and other preventative factors.  However, even so, most midwives typically see less gd and pre-eclampsia than would be statistically expected to occur, which they contend is the result of their very careful prevention work and attention to nutrition.  Most tellingly, midwives who have over time increased their emphasis on prevention through nutrition anecdotally report that they have seen their rates of complications like gd decrease.

Very few doctors emphasize nutrition at all to women.  And many women have reported that what little nutrition information they received from their doctors was erroneous and filled with poor recommendations.  Many doctors truly believe that there is no way that gd can be prevented, and they view their role as simply one of testing early and frequently so that when it 'inevitably' recurs, it can be treated early and intensively.  Most do not believe prevention is a viable approach to gd (with the notable exception of telling women to lose weight before pregnancy, despite a paucity of information on the efficacy and safety of this).  Although there are some doctors who do emphasize nutrition, most ignore the issue or pay minimal attention to it.

Even women who have had gd in past pregnancies rarely receive much nutritional advice from doctors. After Kmom's own first pregnancy with gd, her subsequent OB had no nutritional recommendations for her except to be reasonable.  Kmom had to specifically lobby for an early consultation with a dietitian.  Her doctor and insurance were willing to send her to a dietitian only IF she got diagnosed with gd again.  That's shutting the barn door after the horse is out!  Kmom wanted to see the dietitian FIRST, in order to prevent or minimize things proactively.  With strong lobbying, the OB got the insurance to agree to one visit. This turned out to be a good move because Kmom got a lot of good new information, had a number of questions answered, and was able to avoid gd completely that pregnancy.  

To further illustrate the difference between the midwifery model of care and the traditional allopathic (doctor) approach, the midwife Kmom saw in her 3rd pregnancy further refined this nutritional advice, even though it had worked in the past and Kmom had avoided gd completely in her 2nd pregnancy.  The midwife was not willing to simply rest on past laurels and previous advice, but wanted to be as proactive as possible just in case.  (And yes, Kmom avoided gd with #3 too, despite being near 40.)

Basically, the traditional medical/allopathic model believes that prevention is uncertain and that resources are better allocated to testing for and then treating the condition once it occurs.  When it occurs, treatment most often tends to be pharmacological. The midwifery model believes in PREVENTION INSTEAD OF INTERVENTION, in taking action now rather than risking paying the price later.  It believes that resources are most effective when concentrated on prevention, and that prevention and treatment should START with nutrition first before pharmacology.   The midwifery model is not afraid to use traditional medicine when it becomes necessary, but it believes in working hard to avoid that need whenever possible.    

Please note that these labels do not mean that 'no doctors believe in prevention through nutrition', or that 'all midwives give extensive nutritional analysis'.  There are doctors that practice in the 'midwifery' model, and  'medwives' who despite their training actually practice more in the traditional model.  Just because you hire a midwife for your care doesn't mean that you can assume that she will be more proactive and less interventionist!  Although that is more likely to be true, a job title is no guarantee of beliefs or practices and each provider should be carefully interviewed about their beliefs and protocols.  But in general, the midwifery model teaches prevention instead of intervention, and midwives believe they see fewer/less severe complications because of this.

Another preventative measure they believe can really help is exercise.  As long as there are no contraindications, most midwives promote the importance of regular walking, swimming, or prenatal yoga to their clients.  As noted above, exercise has been shown to cut the rate of gd in half in obese women, and even if the client is average-sized, most midwives promote the importance of daily exercise for prevention.  Stress reduction is also probably very important.  So for most midwives, nutrition, exercise, and stress reduction are the cornerstones to being proactive about a past history of gd.

Unfortunately, in most cases, there are very few formal scientific studies proving that preventive measures like nutrition and exercise help.  For the most part, traditional medicine (with its emphasis on treatment over prevention) simply has not bothered to study this, and alternative models tend more towards anecdotal proof rather than formalized studies.  However, there are some gleanings from the literature that seem to imply that some preventive measures may be helpful (see the websection on Preventing GD for references).  Women with a past history of gd would probably do well to be as proactive as possible under their particular circumstances. 

What If the GD Recurs Anyhow

In some women, genetic or hormonal factors are too strong and gd probably cannot be prevented.  This doesn't mean that these women have 'failed' or cannot be helped.  Having gd recur is NOT a 'failure'.  Genetics are very strong, and an inherited tendency towards diabetes is hard to overcome.  In addition, many women have metabolic conditions such as PolyCystic Ovarian Syndrome which create strong hormonal imbalances, making gd difficult to avoid.  If your gd cannot be avoided, then the goal is to minimize the gd as much as possible so as to have the best possible outcome, and hopefully, less intervention along the way.  

Even if your gd recurs, being proactive about nutrition, exercise and stress levels is not a waste of time.  Minimizing glucose intolerance is definitely a worthwhile goal, and may avoid many problems for you or baby.  For example, some gd moms have found that by being very proactive, they avoided needing insulin in a subsequent gd pregnancy, or were able to reduce their complications.  By demonstrating excellent blood glucose control and being well-informed about the risk-benefit tradeoffs of common procedures, many gd moms have been able to avoid or postpone interventions such as elective cesareans, automatic inductions, standard neonatal intensive care procedures, or have been able to achieve goals like Vaginal Birth After Cesarean, etc.  Being proactive should not be seen only in terms of avoiding gd and complications but also in terms of helping to get a healthier baby and hopefully the kind of birth you want. 

It's important not to see gd recurrence, complications, or birth in terms of 'success' or 'failure', or as a test of your worthiness or dedication.  That's a dangerous emotional trap to fall into.  Although it is important to do everything you can to be proactive, it is also important to not let it dominate your every waking thought or to create more stress.  Some women who dearly want to avoid gd recurrence end up obsessing over every little detail or shift in bG numbers, and drive themselves crazy with anxiety and 'what-ifs'.  (Kmom knows this from experience!) This is understandable but counter-productive to stress reduction.  Be proactive but not obsessive!

Pregnancy should be a time to be enjoyed.  Don't let your quest to be proactive overshadow the joy of carrying a beautiful new life within you, or keep you from bonding with your new precious one.  If your gd recurs despite your best efforts, you have not 'failed', and it doesn't have to mean you can't have a good birth experience or a healthy baby.  In all likelihood, all will go well if you take care.  

Be well-informed and as proactive as possible, but don't worry over every little detail.   As the saying goes, "Do what you can and then let go of the rest."  Don't let the anxiety of  'gd' rob you of the joy that comes with new life.   Enjoy the pregnancy, enjoy the baby, and look forward to the birth and meeting your new little one!

 

References

Recurrence Rates for GD

Spong, CY et al. Recurrence of Gestational Diabetes Mellitus: Identification of Risk Factors. American Journal of Perinatology. January 1998. 15(1):29-33.

164 predominantly Hispanic patients with gd were studied to see the risk factors that influenced the recurrence of gd. 68% of them had gd recur, while 32% did not (note that the population was mostly Hispanic, a group that traditionally has a high recurrence rate and a high rate of type II diabetes overall). Patients whose gd recurred had several common factors in their original gd pregnancy---they were diagnosed slightly earlier, needed insulin more often (25% vs. 8% of the women whose gd did not recur later), had elevated mean plasma glucose levels in the 3rd trimester (fasting 87 vs. 83; 2-hr. postprandial 110 vs. 102), and had more macrosomic (big) infants (26% vs. 10%). No significant differences were noted in this study for maternal age, prepregnancy body mass index, method of delivery, incidence of shoulder dystocia, HbA1c values, etc. "Hispanic patients with history of GDM have significant risk of recurrence in their subsequent pregnancy. The risk for recurrence in women is increased if GDM is diagnosed earlier, they require insulin, have elevated third-trimester plasma glucose level, and deliver macrosomic infants in their index pregnancy. It appears that obesity does not increase the risk of recurrence of gestational diabetes in Hispanics."

Phillipson EH and Super DM. Gestational Diabetes Mellitus: Does It Recur In Subsequent Pregnancy? American Journal of Obstetrics and Gynecology. June 1989. 160(6):1324-9; discussion 1329-31.

The recurrence of gd was examined in 36 women. 20/36 or 56% had full-blown gd recur, meaning that 16 (44%) did not have gd recur.  However, the authors state that 1/3 of the patients did not have glucose intolerance recur so they evidently had an intermediate category of 'glucose intolerance' that was not full-blown gd. Even so, those that did recur tended to be heavier and have had heavier babies, and in particular to have gained weight between pregnancies.  Speculates that the reason 1/3 of women may not have been detected as having glucose intolerance might be because the Glucose Tolerance Test "may not be a reliable test for the detection of abnormal carbohydrate metabolism."  So even when the women with former gd passed all the glucose tolerance tests, the authors remained suspicious about their true glucose tolerance status.  In other words, the GTT tests were 'reliable' and valid for FINDING glucose tolerance but could not be trusted for absolving someone of it!

Foster-Powell, KA and Cheung, NW. Recurrence of Gestational Diabetes. Australian and New Zealand Journal of Obstetrics and Gynaecology. November 1998. 38(4):384-7.

Retrospectively studied 117 women with gd who went on to have a subsequent pregnancy to determine the rate of recurrence and the factors associated with recurrence. Using tighter-than-usual standards, there was a recurrence rate of 70%; using the usual standards the rate was 62.4%. The strongest predictors of recurrence were older age in both pregnancies, and insulin requirement in the initial gd pregnancy. Other factors associated with recurrence (but not as strongly) included non-English speaking country of birth, higher GTT levels, greater prepregnancy Body Mass Index, and weight gain between pregnancies.

Major, CA et al. Recurrence of Gestational Diabetes: Who Is At Risk? American Journal of Obstetrics and Gynecology. October 1998. 179(4):1038-42.

Studied 78 patients with gd to see if it recurred in next pregnancy. There was a 69% recurrence rate; the population was mostly Hispanic (they have higher gd and type II rates). Factors that were more common with women who recurred included more than 1 child (3x risk), Body Mass Index >30 (3.6x risk), insulin requirement in first gd pregnancy (2.3x risk), <24 months between the 2 pregnancies (1.6x risk factor), weight gain of >15 pounds between pregnancies (2.9x risk), and early diagnosis of gd--before week 25--in the first pregnancy (20.4x risk). However, after multiple logistic regression analysis, the factors that were most strongly associated with recurrence were an interval less than 24 months between pregnancies, and a weight gain of >15 pounds between pregnancies. Infant weight, prepregnancy maternal weight, and maternal age were not significantly different between the groups in this study. The factor of time between pregnancies being important is one that doesn't show up much, but in this study, 60% of women with <24 months between pregnancies had the gd recur, while only 21% of the women with >24 months between pregnancies had gd recur. The authors speculate that this may be because women with shorter intervals between pregnancies may have been less likely to lose any excess weight that they might have gained during pregnancy, and women whose weight increased tended to have more recurrence. However, they had no data on this, so it is simply speculation at this point. The authors further speculate that losing weight between pregnancies might help prevent gd recurrence but none of the patients in their study lost a significant amount of weight between pregnancies so they were unable to determine the impact of this variable. Again, researchers are speculating but do not have data. [This study also reviews gd recurrence rates in 3 other studies: 30% in Coelingh, 1977; 36% in Grant, 1986; and 52% in Gaudier, 1992.] The authors conclude that "Gestational Diabetes is more likely to recur in parous, obese women who had an early gestational diabetes mellitus diagnosis and required insulin in the index pregnancy. In addition, a shorter interval (< or = 24 months) and a larger weight gain (> or = 15 pounds) between pregnancies appear to be the most significant risk factors for a recurrence of gestational diabetes mellitus."

Moses, RG. The Recurrence Rate of Gestational Diabetes in Subsequent Pregnancies. Diabetes Care. December 1996. 19(12):1348-1350.

100 women with previous gd and a subsequent pregnancy were studied in Australia. The recurrence rate was 35%. Factors associated with recurrence were an increase in weight between pregnancies, higher maternal age, and greater parity (more pregnancies). Factors not found to be associated with recurrence in this study included higher glucose level, insulin use, or fetal birth weight in the original gd pregnancy. "GDM occurs in only one-third of subsequent pregnancies. Those women who had a recurrence of their GDM were older, more parous, and also had an increase in weight between the pregnancies." Also speculates on the role of dietary modification in preventing recurrence; "learned dietary modifications applied before and/or during a subsequent pregnancy may render that pregnancy 'nondiabetic' to testing."  Once again, authors are suspicious that when gd does not recur, it is still there but 'hidden' from sight.  In other words, any woman with previous gd remains forever branded as glucose intolerant in their sight.

Gaudier, FL et al. Recurrence of Gestational Diabetes Mellitus. Obstetrics and Gynecology. November 1992. 80(5):755-758.

90 patients with previous gd were studied. 52% had a recurrence in the next pregnancy. Women whose Body Mass Index was greater, had more large infants originally, required insulin in the first gd pregnancy, and had higher fasting and GTT values on their first GTT. "Women with a history of gestational diabetes mellitus who have a BMI greater than 35 kg/m2, whose previous newborn was LGA, and who required insulin during their previous pregnancy are at increased risk for recurrence of gestational diabetes mellitus."

MacNeill, S et al.  Rates and Risk Factors for Recurrence of Gestational Diabetes.  Diabetes Care.  April 2001.  24(4):659-662.

Nova Scotia study of a very large database of birth data, so this recurrence study is unusually large.  651 women were identified as having a pregnancy with gd and then another pregnancy after that.  The recurrence rate in this study was pretty low compared to most----36% had gd recur.  However, the authors note that the population was mostly white, and that the 36% recurrence rate was pretty consistent with the rates found in other studies of predominantly white populations. Between pregnancies, 2.5% of the 651 women had progressed on to true diabetes by the next pregnancy.   

Women who weighed >190 lbs. had about a gd recurrence rate of about 51%.  Those gd women who had had a baby weighing >4000g had a 49% recurrence rate.  In both univariate and multivariate  analysis, both macrosomia and high prepregnancy weight was predictive of gd recurrence.  Those who gained >20 lbs. between pregnancies had a 42% recurrence rate, but this did not rise to statistical significance.  Losing weight did not lower the gd recurrence rate.  Time between pregnancies was NOT associated with recurrence. There was no information available from the database as to how the severity of the initial gd was related to recurrence rates.  

They also studied whether gd recurred in a third pregnancy.  Those who had gd in the index (first) pregnancy but avoided it in the next pregnancy had gd recur in the third pregnancy at a 21.5% rate.   Those who had gd in both the first and second pregnancies had gd recur in the third pregnancy at a 72% rate. However, do note that almost 1/4 of those who had gd occur in two pregnancies were able to avoid it in the third pregnancy, which is not bad!

Maternal Weight Changes/Weight Cycling Effects

Pole, JD and Dodds, LA. Maternal Outcomes Associated with Weight Change Between Pregnancies. Canadian Journal of Public Health. July-August 1999. 90(4):233-6.

Examined wt. change between pregnancies in women in Nova Scotia between 1988 and 1996 to see if there was an association for wt. loss or gain with c-sections, occurrence of gd, or Pregnancy-Induced Hypertension (PIH). 19, 932 women were studied. Found that weight GAIN between pregnancies increased the risk for developing gd (about 1.5x relative risk), but did not find that wt. gain OR LOSS was associated with any other outcomes.

Watts, NB et al.  Prediction of Glucose Response to Weight Loss in Patients with Non-Insulin-Dependent Diabetes Mellitus.  Arch Intern Med.  April 1990.  150(4):803-806.

135 obese patients with NIDDM who had lost at least 9.1 kg (20 lbs.) were examined for predictors of improvement in plasma glucose levels after weight loss.  41% of patients were "responders", meaning they had significantly improved plasma glucose levels after weight loss, even after only slight weight loss.  However, 59% were "non-responders" whose plasma glucose levels did not improve even with weight loss.  "We conclude that, in contrast to conventional teaching, many patients with non-insulin-dependent diabetes mellitus will not have any improvement in plasma glucose levels after a 9.1 kg weight loss."  However, a substantial minority will, and this will often show up quickly with even small weight changes. 

Holbrook, TL et al.  The Association of Lifetime Weight and Weight Control Patterns with Diabetes Among Men and Women in an Adult Community.  Int J Obes.  1989.  13(5):723-729.  

Examined 886 men and 1114 women, aged 50+ between 1984-87.  Those who were underweight as children or teens had higher rates of diabetes as adults, especially those classified as overweight now.  (In other words, those who were thin as youngsters and gained a lot of weight later on had the highest risk for diabetes.)   Weight gain OR fluctuation of 10 lbs or more between the ages of 40 and 60 significantly increased diabetes rates, as did significant weight gain after age 18.  Exercise as the only means to control weight was associated with a significantly reduced diabetes rate.  

French, SA et al.  Weight Loss Maintenance in Young Adulthood: Prevalence and Correlations with Health Behavior and Disease in a Population-Based Sample of Women Aged 55-69 years.  Int J Obes Relat Metab Disord.   April 1996.  20(4):303-310.  

Studied weight change patterns of early adulthood and association with disease later on.  Those who were overweight at age 18 but who maintained a stable weight had a risk for diabetes and hypertension higher than those who were normal weight and stable.  Overweight women who lost and maintained the loss had the same risk for diabetes and hypertension as normal weight stable women.  However, weight loss followed by regain was associated with higher odds of disease relative to weight stability in both overweight AND normal weight women.  The highest risk was associated with continuous weight gain or initial weight gain that was maintained. 

Morris, RD and Rimm, RA.  Long-Term Weight Fluctuation and Non-Insulin-Dependent Diabetes Mellitus in White Women.  Ann Epidemiol.  September 1992.  2(5):657-664.

8232 white females who were members of TOPS (Taking Off Pounds Sensibly) between the ages of 40 and 50 were studied to see if long-term weight fluctuation was associated with NIDDM.  An index of weight fluctuation was developed.  Weight fluctuation, waist-hip ratio, relative weight, and family history all showed increased risk for diabetes.  "The results suggest that the magnitude of long-term weight fluctuation is associated with the development of NIDDM."

Importance of Early Glucose Testing in Subsequent Pregnancies

Wein, P et al. Factors Predictive of Recurrent Gestational Diabetes Diagnosed Before 24 Weeks' Gestation. American Journal of Perinatology. September 1995. 12(5):352-6.

This Australian study looked at which factors in the original gd pregnancy were most associated with the diagnosis of EARLY gdm (before 24 weeks) in a subsequent pregnancy. Multivariate analysis of 180 cases showed that women with early recurrent GDM were more likely to have needed insulin in the first gd pregnancy (11x risk), to have had a macrosomic infant (4x risk), to be more often of non-Northern European origin (5.5x risk), to be over 30 years of age (2.3x risk), or to have had severe gd in the first gd pregnancy (3.5x risk). Factors that were NOT associated with early recurrent GDM in this study included obesity, family history of diabetes, fasting plasma glucose levels, and parity (# pregnancies). "However, even without any of the significant risk factors, logistic regression modeling suggested that a woman who has had GDM in a previous pregnancy has a 5.1%...chance of having early recurrent GDM. We therefore continue to recommend that all women who have had GDM diagnosed previously should have glucose tolerance testing performed early (before 24 weeks' gestation) in any future pregnancies."

Farrell, J et al. Gestational Diabetes--Infant Malformations and Subsequent Maternal Glucose Tolerance. Australian and New Zealand Journal Of Obstetrics and Gynaecology. February 1986. 26(1):11-16.

86 patients with gd were followed up (Group 1=54 insulin-requiring; Group 2=32 diet-only). Of these gd pregnancies, there were 4 major congenital malformations (4.7%) and 13 minor malformations (15%) with no difference in frequency between group 1 and 2. (Note that this was in the very early days of gd treatment and treatment standards and regimens were more uneven then; also note the very high number of women in this study who went on to glucose intolerance or outright diabetes within 1 year, indicating that these gd patients probably had more severe cases and some glucose intolerance previous to the pregnancy, which may explain the higher rate of malformations and later glucose intolerance). Within 1 year, the cumulative prevalence of outright diabetes in 42 women returning for follow-up was 26%; the cumulative rate of those with abnormal glucose tolerance (Impaired Glucose Tolerance and Diabetes both) was 33%----both very high rates. Although these rates are much higher than usually found, it does point out that some patients MAY well progress to glucose intolerance or outright diabetes within a year or so postpartum, and early testing in subsequent pregnancy may be vitally important if this happens.

Dong, ZG et al. Value of Early Glucose Tolerance Testing in Women Who Had Gestational Diabetes in Their Previous Pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology. November 1993. 33(4):350-357.

1,027 women with previous gd were analyzed in a subsequent pregnancy. Group One had early testing plus testing at the usual 28 weeks (49.4% recurrence of gd; 62% of those were early). Group Two had testing at the usual time only (34% recurrence of gd). Group Three did not have their glucose tolerance tested in the next pregnancy. The risk of emerging Diabetes on follow-up was greater in women who had been diagnosed earlier in pregnancy. Perinatal Mortality Rates in the subsequent pregnancies were 2.2% in Group 1; 0.6% in Group 2; and 3.1% in Group 3. Analysis of the 13 perinatal deaths revealed that 5 were potentially avoidable according to the judgment of the authors (i.e. 3 of the early recurrent gd cases in group 1 that had perinatal deaths were never given insulin), but it's important to note that this is simply speculation on the part of the authors and not established fact. Still, the authors feel that "this study suggests that early diagnosis of gestational diabetes may allow further reduction of perinatal mortality."

Effect of Further Pregnancy on Future Diabetes Risk

Peters, RK et al. Long-Term Diabetogenic Effect of Single Pregnancy in Women with Previous Gestational Diabetes Mellitus. The Lancet. January 27, 1996. 347(8996):227-30.

Studied 666 mostly Hispanic women who had gd and then attended a high-risk family planning clinic, with a sub-study of 87 of these women who went on to have a subsequent pregnancy after a gd pregnancy. 91% of those who were tested had gd recur, an extremely high rate. Then it went on to compare the rate of progression to Type II Diabetes (NIDDM) in the women who had had a subsequent pregnancy and the women who did not have a subsequent pregnancy. To their surprise, they found that the women who had one additional pregnancy had a more than threefold risk of developing NIDDM compared to the women who did not have an additional pregnancy. Notes that in the general population, parity (# of kids) has been shown to have little effect on the development of NIDDM. Speculates that in a group of women with a high genetic tendency towards diabetes, however, the influence of a single pregnancy may offer a "metabolic insult" to the system and may increase the rate of progression towards diabetes. Notes that this has not been shown in other studies and more study is needed, and further study is also needed to see if this effect holds in other ethnic populations (Hispanics have an extremely high rate of type II diabetes). Also notes that in this study, each 10 lbs. gained after pregnancy almost doubled the risk for developing NIDDM; notes that in the *much* smaller group that lost weight after pregnancy, there was the lowest risk for developing NIDDM (although conclusions are limited because of the small sample size of this group). It's very important not to jump to conclusions on this study too soon; this is a PRELIMINARY STUDY and may not hold up to further examination, or it may be true more for certain high-risk populations than for all populations. Don't choose NOT to have more kids because of this one study but do be aware of its implications, if it turns out to be true.

Exercise/Prevention in GD

Dye, TD et al. Exercise Cuts Rate of Diabetes in Pregnancy in Obese Women. American Journal of Epidemiology. December 1997. Summarized from a press release from Doctor's Guide to Medical and Other News, at www.pslgroup.com/dg/4a5ce.htm.

This study looked at the effect of exercise during pregnancy on the rate of the development of glucose intolerance. Little effect was found for women of average size or those somewhat 'overweight'. However, in women who were significantly obese (Body Mass Index of 33 or more; the usual recommendation for women is a BMI of <25), exercise had a definite preventive effect. Women with BMIs of 33+ who did not exercise were twice as likely to develop gd as their counterparts who did exercise. Curiously, the amount and frequency of exercise showed little difference in benefit; the important factor was the presence of absence of exercise.

Bung, P et al. Exercise in Gestational Diabetes: An Optional Therapeutic Approach? Diabetes. 1991. 40(Supplement 2):182-185.

41 gd patients with abnormal fasting levels who failed a diet therapy trial of 1 week were randomized to either diet+exercise or diet+insulin. The exercise group did 45 minutes of exercise 3x per week in a lab with medical supervision. 17 patients in each group finished the study. No differences were seen between the groups in terms of blood sugar determinations, complication rates, or fetal health (remember that the exercise group did not have insulin; they achieved the same results as the insulin group WITHOUT insulin). The exercise group delivered slightly later on average (38.9 weeks vs. 38.2 weeks), perhaps because of differences in physician management (insulin-treated women are usually induced at 38-39 weeks, non-insulin women generally are induced a week or so behind this schedule).

Dicker, D et al. Pregnancy Outcome in Gestational Diabetes with Preconceptional Diabetes Counselling. Australian and New Zealand Journal of Obstetrics and Gynaecology. August 1987. 27(3):184-7.

Followed 136 women with previous gd but normal glucose tolerance between pregnancies who were given preconceptional counseling by a diabetological team for at least 2 months before conception, compared to 154 women with gd at various stages of pregnancy (presumably first-time gd, not recurrence, so the groups are not totally comparable). The group with preconceptional counseling (including nutritional counseling and close monitoring of bG) had better glucose levels, less maternal complications, less c/s rates, less congenital anomalies, and less macrosomia and hypoglycemia.

C-Sections and VBACs in GD Pregnancies

Coleman, TL et al.  Vaginal Birth After Cesarean Among Women with Gestational Diabetes. American Journal of Obstetrics and Gynecology.  May 2001.  184(6):1104-7.

First significant study to examine gd and vbac specifically.  Retrospective cohort study over 11 years of 156 women with gd who had had one prior cesarean delivery and who underwent a Trial Of Labor (TOL). There were 272 controls who were matched for year of delivery and history of one prior c/s.  Those identified as having gd were seen at an obstetric endocrine clinic by maternal-fetal medicine specialists (meaning they got treated as 'high-risk'). The population was mostly made up of indigent women from an inner-city population in Atlanta.  

Women with gd were older and more likely to be white or Hispanic.  Women with gd who wanted a TOL were required to have an ultrasound estimate of fetal weight in the third trimester; if the EFW was >4000g, elective repeat cesarean (ERCS) was recommended.  Authors do not provide info, however, on how many had an EFW > 4000g and therefore had an ERCS, nor on how many of these estimates were correct or incorrect.  This would have been interesting info to have.  

Women with gd who had a TOL had more 'abdominal deliveries' (35.9%) than the controls (22.8%). In other words, the VBAC rate was 64.1% for the gd moms overall vs. 77.2% for the controls.  Although lower, 64% is still an acceptable VBAC rate and well worth pursuing, although of course, the abstracts only states it negatively by noting that women with gd are 'less likely to have a successful trial of labor' and should be 'appropriately counseled about the risk'.  That means that most OBs are going to discourage women from trying by telling them that they are less likely to have a VBAC, which moms will interpret as having very little chance, when in fact the chances are that almost 2 of 3 gd moms would have a VBAC!  

But the real story of this study lies in the subanalysis of those induced vs. those who had spontaneous labor.  Of those gd moms who labored spontaneously, 81.3% had a successful VBAC!  This was still lower than the controls who labored spontaneously (who had a 90.5% VBAC rate), but even so, an 81% VBAC rate is still outstanding, and better than the 60-80% success rates cited by the study as being 'typical'. If allowed to labor spontaneously, more than 4 of every 5 gd moms had a VBAC.    

On the other hand, GD moms were almost 2x more likely to be induced (38.5% induced, vs. 22.4% induced in controls).  Of those who were induced, only 36.7% had a VBAC.  Going from an 81% VBAC rate down to 37% meant that inducing in this study cut the gd VBAC rate in half, which makes a very strong case for 'allowing' spontaneous labor instead of automatically inducing gd moms!  Interestingly, the results were even worse for the controls who were induced; only 31% of them had a VBAC.  From 90% VBAC down to 31% VBAC----this study makes a strong case for not inducing VBACs, even among normoglycemic women!  And gd moms having a VBAC had no more shoulder dystocia statistically than normoglycemic moms, despite a higher rate of instrumental deliveries (which was foolish, considering that instrumental deliveries quadruple the chances for shoulder dystocia!).    It would have been interesting, however, to be able to compare the shoulder dystocia rate for induced gd moms vs. the rate for spontaneously laboring gd moms.  

There were 2 uterine ruptures among the controls (0.7% rupture rate) vs. 0%  ruptures among the gd moms (despite their higher induction rate!). Taking the two groups together, the overall VBAC rate was 72%, with an overall rupture rate of 0.5%.  

Emotional Recovery From Childbirth/VBAC Resources

Madsen, Lynn. Rebounding From Childbirth: Toward Emotional Recovery. Westport, Connecticut: Bergin and Garvey, 1994. Available from www.amazon.com.

SUPERB book about recovering emotionally from childbirth and pregnancy. A bit flakey and 'New Age' in a few parts, but overall is just excellent. Highly recommended!

Panuthos, Claudia. Transformation Through Childbirth: A Woman's Guide. Westport, Connecticut: Bergin & Garvey, 1984. Available from Cascade Press/Birth and Life Bookstore - (503) 371-4445 or (800) 443-9942.

THE BEST BOOK on emotional preparation for or recovery from birth. Kmom's highest recommendation possible! Unfortunately, out-of-print now, but Cascade Press has a few left. If you can afford it, GET THIS BOOK.

Korte, Diana. The VBAC Companion: The Expectant Mother's Guide to Vaginal Birth After Cesarean. Boston: Harvard Common Press, 1997. Available from www.lalecheleague.org.

THE best book on VBACs around! Superb! Very supportive of mothers considering VBACs, even those who choose not to pursue them. Extremely informative without engaging in excessive rhetoric; excellent questions for choosing a provider to assist in a VBAC and designing a birth plan. Also has a good section with valuable tips on helping to overcome common obstacles to a VBAC, and addresses the emotional issues of c-section and VBAC 'trials of labor' well.

Crawford, Karis and Johanne C. Walters. Natural Childbirth After Cesarean: A Practical Guide. Cambridge, Massachusetts: Blackwell Science, Inc., 1996. Available from www.lalecheleague.org.

Another excellent book about preparing for a VBAC, with an emphasis on the author's own professional expertise and personal experiences. Presents many suggestions for planning a VBAC.  Also has a very good picture of an optimally-positioned baby that is good to copy and post around the house and use in your visualizations.

Flamm, Bruce. Birth After Cesarean: The Medical Facts. New York: Simon and Schuster, 1990.

Early book establishing the safety and viability of VBACs, complete with medical references, written by the author of world's largest study on VBAC. Since it was based on information gathered in the 80s and VBACs were considered a fairly risky endeavor then, it tends to be a bit conservative in some of its recommendations (mandatory continuous electronic fetal monitoring, for example) but it is a good overview of VBAC issues from a medical research perspective.

Other Pregnancy Resources

Weschler, Toni. Taking Charge of Your Fertility. Available from www.amazon.com.

EXCELLENT book on understanding your fertility cycles and using this knowledge to either achieve or avoid pregnancy. Promotes the Fertility Awareness Method (FAM), which is similar to Natural Family Planning but without the religious context or required abstinence, for those who do not choose these. Uses the sympto-thermal approach, which involves charting basal body temperatures and observing cervical mucus and position. With adequate education and strict user compliance, the failure rate is quite small and comparable with many of the artificial forms of birth control, though many women conversely use its knowledge of peak fertility times to help achieve pregnancy instead. One of the finest, most useful books Kmom has ever read.

Noble, Elizabeth. Essential Exercises for the Childbearing Year. Fourth Edition. Harwich, Massachusetts: New Life Images, 1995.

Book detailing optimal exercises before, during, and after pregnancy. A valuable resource.

Behan, Eileen.  Eat Well, Lose Weight While Breastfeeding. New York: Villard Books, 1992. 

A book about losing weight 'sensibly' while nursing, without endangering your milk supply or endangering your baby.  Available from www.lalecheleague.org. 

 


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